KIN 423 Exam 2

laser for pain control

-common laser selections: -superficial-HeNe laser, 1-3 J/cm2 -deep-GaAs laser, 1-2 J/cm2 -gridding application -open-pack joint position -treat from distal to proximal

drum electrodes

-induction -one or more monopolar coils rigidly fixed in a housing unit -may use more than oe drum depending on area treated -toweling important -absorbs moisture (sweat) that could overheat and create hotspots -penetrations tends to be on the order of 2-3cm

pulsed shortwave diathermy

-interrupted output delivered in series of high frequency bursts (20-400usec) -pulse rate selected with pulse frequency control -off-time longer than on-time -low mean power output -uses drum electrodes

extrinsic duty cycle

-"on-off" time -set by the clinician (not available on all currents) -serves a rest period -modulates depth based on carrier frequency -reduces risk in high current treatments (medium Hz) ( exmaple is russian stimulation for muscle education) -used mainly in motor stimulation not sensory

type 3b laser

-AEL between 5 and 500 mW -dangerous if directly viewed -most common classiication for therapeutic devices

type 3a laser

-AEL up to and including 5mW -must not be viewed using optics -laser pointers and firearms

photons

-EM transmitted as waves containing photons -photons are: -the basic unit of light -a packet or quanta of light energy

SWD compared to US

-SWD may be more effective heating modality -able to treat larger area -stationary heating modality which eliminates fluctuation in heating -rate of temperature decay is slower following diathermy application

laser photon production

-a laser consists of some type of gain medium -material (gas, liquid, solid) with optical properties -contained inside an optical/lasing chamber -photons bounce back and forth in lasing chamber and hits gain medium which then produces an output beam(laser) -waves gain amplitude unitl they can pass through the portal

ionotophoresis

-a version of galvanic current that introduces transcutaneous delivery of water soluble drugs -not just any monophasic stimulator -when used on skin with a water soluble drug, as we apply direct current, the bonds and channels start to get wider and lets some things through. if particles of medicine are small enough and is the same charge as the current, teh medicine will be repelled and allows the medication to be transported into the skin -hyperlocalized treatment to help symptoms -importnat to pick correct polarity becuase if you dont then it wont be effective and will introduce monophasic current alone which could increase the risk of burning -make sure to check in after 1-2 min to make sure there is no burning sensation. a anesthetic effect may mask the sensation

voltage

-also called electrical potential difference -magnitude of difference in electron density between (+) and (-) poles of a system -higher voltage=more intense treatment -changing the grequency can give the sensation of the intensity (voltage) -its the knob you turn

mechanical effects of mechanical energy

-always accompanied by some reflex effects -as mechanical stimulus becomes more effective, reflex stimulus becomes less effective -effects on muscle -mechanical stress on intramuscular connective tissue -increase blood flow to skeletal muscle -to increse range of motion -does not increase strength or muscle tone -effects on skin -increase in skin temperature -increases sweating -mechanically loosens adhesions and softens scar -increases pliability of fibrous scar tissue

athrogenic inhibition

-application of disinhibitory TENS -trying to overcome the source of muscle inhibition -pain receptors and mechanoreceptors aroudn the joint send information back to the spinal cord which does local processing (makes in teh moment decisions-reflexes etc) -after ACL reconstruction. the other strong side will present 20-30% weaker. body wants to compensate and it wants us to stay away from activities that will cause further injury -spinal cord also decides when it should tell the brain because the brain can re-organize processes which cements reduced muscle fuction on both the injured and non-injured side (protective mechanism) -can introduce a competitive stimulus at the joint. can put a pre-mod current around the joint, the CNS gets bombarded with new info and it decides that there must no longer be an injury. by doing thsi you see a 10-30% increase in force output. only works when the current is on though gives you a window of oppurtunity treatment where you can pair stim with muscle contractions and exercises to gain and re-build muscle to prevent atrophy. very helpful treatment.

contraindications for SWD

-application over cardiac pacemaker, eyes, genetalia, joint replacements, and metal implants -pregnancy -open wounds -cancer -infection -deep vein thrombosis -acute inflammation and joint effusion -diminished or absent sensation

clinical application of laser

-biologic and physiologic effects from laser are still being explored -effective at reducing pain and aiding in wound healing -acceleration of collagen synthesis -decrease in micororganisms -increased vascularization -anti-inflammatory action -increased cell metabolism

pulse

-bipasic: both phases on (+) and (-) -monophasic: pulse is exact same as phase

pulse duration

-biphasic: time for it to go through 1 (+) and (-) phase -monophasic: time for it to go through 1 period of (+) or (-)

phase duration

-both positive and negative phase -to modify frequency you can change the interpulse interval or the phase duration or both -length of time in which the (+) or (-) flow is happeneing

contraindications for laser

-cancerous tumors -directly over eyes -pregnancy -it is better to underexpose than to overexpose!

air space plates

-capacitor -two metal plates surrounded by plastc guard -can be moved 3cm within guard -produce hig-frequency oscillating current -when overloaded discharges to plate of lower potential -sensation of heat in direct proportion to distance of electrode from skin -closer plates generate more surface heat -parts of the body low in subcutaneous fat are best treated by this method -patient part of circuit -must have uniform contact (toweling) -spacing equal to cross-sectional diameter of pads -part to be treated should be centered -increasing the spacing will increase teh depth of penetration but will decrease the current density

laser safety

-class 1: nonhazardous to the body, needs indicator light to identify when laser is engaged -class II: low-power, hazardous only when patient directly stares into the light source -class III: moderate-risk, both operator/patient required to wear eye wear, do not cause serious skin injury -class IV: high-power, high risk of injury, combustion of flammable materials

types of massage techniques

-classical massage technique which uses a variety of superficial strokes -effleurage -petrissage -tapotement -vibration

laser for scar tissue

-common laser selection: -GaAs laser 0.5-1J/cm2 -hypertrophic scars -pain and edema associated with scars are effectively treated as well -better when vascular network is present

laser for edema and inflammation

-common laser selections: -acute: GaAs laser 0.1-0.2J/cm2 -subacute: GaAs laser 0.2-0.5J/cm2 -reduced interruption of chemical mediator formation -kinins -histamines -prostaglandins -laser optimizes cell permeability -gridding application -can help restart acute inflammatory phase

petrissage (kneading)

-consists of kneading manipulations that press and roll muslces under fingers or hands -muscles are gently squeezed, lifted and relaxed -increases venous and lymphatic return -mechnically migrate metabolic waste

clinical applications for diathermy

-continuous SWD used for thermal effects -mixed results associated with changes in flexibility and joint stiffness -slighlty dangerous -rapid heating -rationale for selection: -skin is tender and will not tolerate pressure -subcutaneous fat is thick and deep heating is required -to increase tissue temperatures in a large area

laser treatment dosage

-determines treatment time - T=(E/P) x A -T=treatment time for a given area -E=mJ of energy per cm2 -P=average power of the laser (mW) -A=beam area in cm2

endogenous contraction

-driven by the volitional activation of the patient -slow twitch fibers are recruited first -physiological

phase

-each pulse is also a phase -on-time -pulse and phase are same thing in monophasic current -in biphasic current the pulse is usually twice the pulse -period on where there is either a (+) or (-) flow

physiological changes produced by stim

-either getting sensory peripheral nerves to depolarize so it cant sense pain -stimulating a motor neuron to get a muscle to activate by using alternating current with a range of frequencies. used most often (95%)

exogenous contraction

-electrical -triggered by an external stimulus -results in an all-or-none type of contraction -amplitude exceeds threshold -phase duraction exceeds capacitance -ramp time is fast enough to prevent accomodation -large diameter motor nerves depolarize first -low capacitance -related to fast-twitch muscle fibers

contraindications for TENS

-electrode placement over carotid artery -cardiac pacemaker -pregnancy

contraindications for iontophoresis

-electrode placement over carotid artery -pregnancy -medications to which individual is allergic or hypersensitive

application of high volt

-electrode placement: -monopolar is most common -bipolar is possible -dispersive electrode required -varied applications -can be used with: -submersion techniques

important factors of current density

-electrode size -inter-electrode distance( how far away electrodes are influence how deep teh treatment will go) -electrode contact(good contact between electrodes and skin) -interelectrode dstance is similar to frequency in US. pads closer together give a more superficial treatment and pads farther apart give a deeper treatment -only exception to electrode contact is a single point stimulation

effleurage technique (stroking)

-every massage begins and ends with effleurage -increases venous and lymphatic flow -increases circulation to skin surface -deep stroking is a form of effleurage, ecept it is given with more pressure to produce a mechanical effect

indications for laser

-facilitate wound healing -pain reduction -increase the tensile strength of a scar -decrease scar tissue -decrease inflammation -bone healing

vibration techniques

-fine tremulous movement, made by hand or fingers placed firmly against a part causing a part to vibrate -manual or mechanical

noxious TENS

-goal: generate competing painful stim -pain: stimulation of descending serotogenic tracts -target population: myofascial conditions (chronic) -method of application: point stimulator -effect duration: 1-3 hours for a 30 min treatment -also uses gate-theory like sensory stim -want to use smallest electrode you can get -will rarely or never use

medium and high stimulation frequency

-greater than refractory period -results in neural inhibition (wedenskis inhibition)- no longer able to get therapeutic effect -medium=pain modulation (1,000-100,000 Hz) -high=thermal effect(>100,000 Hz) -dont do anything in high range or higher than 2,000 Hz in medium range -nerve needs time to recharge (refractory period)- released ions built up so it needs time to ocme back to neutral before firing again. if theres not this time, it can have negative effects physiologically and can make the patients pain worse or possibly result in burning -tetanic contraction: what happens when we dont let the refractory period occur (russian stimulation)

laser parameter selection

-greater wavelength=greater penetration -helium-neon (HeNe)-red laser -wavelength=623nm -power output=1-25mW -depth of penetration=6-10mm -indium-gallium-aluminum-phosphide(InGaAIP) -wavelength=630-700nm -power output=1-25mW (highly variable) -depth of penetration=6-10mm -Gallium-arsenide (GaAs) -wavelength=904nm -power output=1-100mW -depth of penetration=30-50mm -Gallium-Aluminum-Arsenide(GaAIAs) -wavelength=800-830nm -power output=30-100mW (can exceed 1,000mW) -depth of penetration=30-50mm

physiochemical changes produced by stim

-happen when you pump ions of a specific charge into a concentrated area (tissue) and letting them accumulate making changes in things such as pH balance of a tissue or increse its membrace potentials or increase the healign of tissue. (monophasic, galvanic). ionto is an example of this (high volt).

indications for SWD

-heat large area of deeper tissue -increase blood flow in deep tissues -decrease pain and muscle spasms

type 4 laser

-high power lasers -AEL > 500mW -can be hazardous to eyes and skin -can produces an intense thermal effect

diathermy

-high-frequency electromagnetic energy -used to generate heat in body tissues -not capable of producing depolarization of muscles -heat produced by resistance of tissues -able to heat greater than 5cm

type 1 laser

-incapable of producing damaging radiation -generally eye safe

variables in laser

-laser light is emitted in an organized manner -3 properties distinguish laser: 1.coherence: photons of identical phase and time relationship 2.monochromaticity: light source produces a single color or wavelength 3.collimation: to make photons parallel

laser

-light amplification for the stimulated emission of radiation -electromagnetic energy -infared and visible light portiosn of the spectrum

monochromaticity

-light source provides a single color or wavelength -helium and neon produces red light

type 2 laser

-low power visible lasers (400-700nm) -AEL < 1.0 mW

rhythmical motor TENS

-low rate TENS or acupunture like TENS -pain theory- rythmical pain modulation -release of endogenous opiates to inhibit descending pathways -effect duration; 1-3 hours for a 30 minute treatment -shouldnt pair with another treatment -under 30 minute treatment considered non-effective, aim for 30-45 min treatment -want to use it alone. if heated it would make it harder to contract muscle so its not as effective

rheobase

-lowest amplitude to result in nerve depolarization -requires long phase duration that may be uncomfortable -possible risk of burning

NMES

-manual parameters -at least phase duration of 250 -at least 50pps -allows us to overcome capacitance of alpha motor neurons when amplitude and intensity is high enough -can change parameters so stim is doing all, some or none of the work to produce a muscle contraction

parameters of iontophoresis

-maximum current: 5mA -treatment rate=80mA-min -high and low amplitude -similar treatment effectiveness -25-30 min treatment (depends on patient toleration)

effects of manual therapy

-mechanical stimulation of tissues by rythmically applied mechanical compression or tension -reflexive: effects sensory and motor nerves locally and some central nervous system response -mechanical: meakes mechanical or histological changes in myofascial structures through direct force applied superficially. initiate lymphatic system uptake, decrease edema/swelling.

type 3 laser

-medium power lasers -generally not eye safe

High voltage stim

-minimum 150 V capacity- deep conductance -monophasic current (2-120pps) -twin-peaked waveform- prevents a-delta and c-fiber stimulation -long interpulse interval -doesnt stimulate slow adapting pain fibers (a-delta, c-fibers) -not used often, doesnt seen to be very effective -pre-mod and IFC are safer and just as effective -not much evidence

NMES parameters

-must include a duty cycle -usually 1:5 on to off (based on membrane re-polarization) -will reduce muscle fatigue while increasing treatment time -phase duration of 250-300us -overcomes the capacitance of the motor nerve -tetanic contraction -30-50pps -ramp time -depending on comfort level -must be considered when setting the on time

ionto current and medication

-nonophasic direct current -long phase duration -strong polar effects - +=anode - -=cathode -medicine: dexamethasone (-), lidocaine(+), hydrocortisone(+) salicylate(-) -patients need a prescription in order to be given this treatment

interpulse interval

-off time, time in between when we have current -time in between pulses when electrical energy is not being emitted -important when trying to innervate a nerve, on-time causes depolarization and off time allows for repolarization of the nerve

resistance (ohm's)

-opposition to electron flow -determined by the surface/interface -skin is a powerful resistor -always resistance present in electrical circuit

indications for TENS

-pain contron -restore neuromusculsar control -retard atrophy

short wave diathermy dosing

-patient sensation provides basis for recommendations of continuous SWD: -Dose I (lowest) -no sensation of heat -does II (low) -mild heating sensation -dose III (medium) -moderate or pleasant heating sensation -does IV (heavy) -vigorous heating within pain threshold

chronaxie

-phase duration at 2x rheobase -indicated initiation of the comfortable treatment -can get physiologic effects without discomfort

parameters for motor stim

-phase duration: 200-300 us -amplitude: strong motor -pulse frequency: <10 pps -target nerve fiber: A-delta

rhythmical sensory stim parameters

-phase duration: 200-300 us -pulse frequency: 2-4 pps -amplitude: strong muscle contraction -target nerve fiber: A-delta

parameters for neuromuscular stim

-phase duration: 250 us -amplitude: motor -pulse frequency: 50 pps -target nerve fiber: A-alpha

sensory TENS treatment parameters

-phase duration: <100us -pulse frequency: >100 pps -amplitude: sensory, sub-motor -target nerve fiber: A-beta

parameters for sensory stim

-phase duration: <150 us -amplitude: submotor -pulse frequency: 60-120 pps -target nerve fiber: A-beta

parameters for noxious stim

-phase duration: >300 us -amplitude: painful -pulse frequency: high or low -target nerve fiber: C fiber

coherence

-photons of identical phase and time relationship -wavelengths are the same and in phase

average amplitude

-physiochemical effects are produced -root mean square

low stimulation frequency

-physiologic effect -less than refractory period <1,000Hz

uses for galvanic current

-polarity of current has an effect -long phase duration (>1s) -changes pH under the active -polarity + pad choice= effect -not used in young athletes

clinical positioning of SWD

-positioning will allow relaxation, prevent fatigue, and permit free movement of arms, hands, and body -weight evenly distributed between legs -fit your hands to contour of area being treated

Russian stimulation

-preset parameters -can produce a strong tetanus contraction -endogenous contraction supplemented by exogenous stimulation -pad placement over the muscle can be bipolar or quadpolar -obvious when we hit the right intensity becuase we see the muscle contraction -phase duration: 200-300us -pulse frequency: 30-50Hz -ramp time: 1-3s -duty cycle: 1:5 on-off time

treatment considerations of SWD

-pressure regulation determined by the type and amount of tissue present and patients condition -lymphatic effects > 30 mmHg -reflexive effect pressures are unclear -duration depends on: -severity of pathology -size of the area being treated -demographics -direction of forces should paralled muscle fibers -begin and end with effleurage -make sure patient is warm, comfortable and relaxed -body part may be elevated if necessary most common in effleurage -sufficent lubricant should be used -stroke should overlap -pressure should be in line with venous flow followed by a return stroke -all strokes should be rythmic

friction massage

-purpose: -loosed adherent fibrous tissue (scar) -aid in edema absorption -reduce muscle spasm -produce reflex effects -small movements directed at underlying structures beneath superficial tissues -normally use thumb to provide direct pressure -small localized treatment area -used prior to another treatment -hurts bad at first then feels better

sensory stimulation

-rapid leading edge -short ramp time -excites sensory nerves -best for pain modulation -skin can acclimatize to the sensation so there has to be rapid fluctuation between electrical energy and it must reach peak amplitude quicklly -results in nerve confusion which prevent acclimatization of the sensation -nerves adapt very quickly -need low ramp time and need to vary the frequency of the amlpitude and frequency so that there is no nerve adaption

ampere

-rate of electron flow at a given point -flow of electrons from (-) to (+) concentrations

impedance

-resistance + inductance + capacitance -inductance: wait till diathermy -capacitance: charge storage

reflexive effects

-skin contact stimulates cutaneous receptors -reflex mechanism is believed to be an autonomic nervous system phenomenon -stimulus causes sedation, relieves tension, increases blood flow -effects on pain -modulates pain through gate control and B-endorphins -effects on circulation -increases blood flow -light touch causes transient dialation of lymphatics and small capillaries -increased lymphatic flow -assists in removal of edema -effects on metabolism -does not alter general metabolism -no alterations in acid-base equillibrium of blood -no significant effects on cardiovascualr system -assists in removal and hastens re-synthesis of latic acid

motor stimulation

-slow leading edge -long ramp time -excites motot tissue -excludes sensory tissue -requires ramp time (no energy-> peak amplitude) -want progressive depolarization of muscle fibers so it results in a natural contraction -want to decrease amplitude so the patient is doing more of the contraction -opposite of sensory -long ramp time allows us to achieve tetany and maintain tetany in a comfortable position -not meant to go from no energy to max energy -predictable amplitude/ consistent frequency

elements needed for electrical current (flow) to exist

-source of electrons -a conducting material -a driving force of electrons

laser for wound healing

-superficial: -acute: HeNe laser, 0.5-1J/cm2 energy density -chronic: HeNe laser, 4J/cm2 energy density -Deep -acute: GaAs laser, 0.05-0.1J/cm2 energy density -chronic: GaAs laser 0.5-1J/cm2 energy density -clean all debris from wound -scanning application -can cover wound with clear plastic sheet for direct contact

coulombs

-the magnitude of charge in an area

shortwave diathermy field

-the tissue that offers the greatest resistance to current flow develops the most heat -fat tissue resists current flow, thus fat is heated in an electrical field -subcutaneous fat tends to overheat due to resistance -typical occurence with capacitor electrodes

phase duration

-time from isoelectric departure to return (ms) -same as pulse duration in monophasic current -determinant of tissue rsponse (not pulse duration) -high capacitance tissue needs increased phase duration -dehydration, calluses, and body hair increase resistnace so you may need to slightly modify the parameters

physiologic responses to diathermy

-tissue temperature increase -increased blood flow -increased venous and lymphatic flow -increased metabolism -changes in physical properties of tissues -muscles relaxation -analgesia

collimation

-to make photons parallel -why you get a beam of light -can travel greater distances

precautions of SWD

-toweling to absorb perspiration is a must -be sure that there are no overlapping skin surfaces (i.e. towel should be placed between skin folds in axilla) -monitor areas that are covered by clothing (synthetic fabric may not allwo evaporation of moisture) -maintain safe distance from other medical devices -metal tabels and chairs should not be used (watches and jewelery should not be worn as electromagnetc energy could magnetize watch or heat jewelry) -patient must remain in a comforatble position for the duration of the treatment -movement could disrupt field -body part being treated should be elevated or horizontal during treatment

general parameters for sensory stim

-treatment duration: 10-45 minutes (highly variable) -pain theory: gate theory -duration of effect: durign treatment/up to 30 minutes -main indication is pain control -noxious introduces a pain that is slightly worse than the original pain to make it feel less intense -much more likely to use sensory and rythmical stim in the clinical setting -duration of effect depends on the person. when pads are taken off, therapeutc effect immediately diminishes. doing it by itself makes it not as effective -pair with heat or ice

interferential stimulation units

-two medium frequency currents to increse depth -medium/ high frequency current reduces skin impedance -currents must be modulated -must trigger enkephalin intervention at the dorsal horn -2 channels about 100-150 Hz apart from each other -collision of waves will create a new e-stim current in middle that is = to the difference in frequency between the two -allows you to treat a much larger area(clover leaf) -carrier frequency is lower number (number it should start from) between 3000-6000 is a safe range. machines usually defalut to 4000. only thing needed to change is end result (150 bps) -IFC used for pain control. want to be within 80/150 Hz -by using IFC we get a collision of particles with different frequencies which allows a broader treatment area. can treat a larger area of pain (back).

shortwave diathermy electrodes

-types -capacitor electrodes -induction electrodes -capacitance and induction impact different tissues

tapotment (percussion)

-uses a variety of percussive or beating techniques -used to increase circultion and blood flow -used to stimulate peripheral nerve endings -hacking/cupping or clapping

neuromuscular control

-volitional muscle contractions affected by: -swelling and pain -altered mechanoreceptor input -components of NM control -volitional contractions -reflex reactions -complex functional movements -strenghtneing vs force capacity -strengthening: 40-60% max voluntary force -NMES: enhance muslce ability to contract (requires long phase duration >250us) -educates muscle and reduces atrophy after surgery -can educate non-injured side and prevent atrophy on injured side (cross-over) -dont want to stimulate pain control fibers want to stimulate alpha motor neurons -doesnt produce larger muslce, just maintains size

indications for iontophoresis

-with dexamethasone: chronic inflammation -with lidocaine: local anesthesia

amount of joules needed

-wound healing: 4-35J -Revascularization: 2-3J -pain relief: 1-7J -muscle spasms: 2J -circulation: 1-3J -nerve stimulation: 0.1-0.5J -nerve cell regeneration: 2J -inflammaotry condition: 1-3J -chronic conditions: 3-6J

treatment protocol for laser

1. determine the area to be treated and visualise a grid overlying the treatment area. the grid should be divided into 1-cm squares 2. if the griddign technique is to be used, place the tip of the probe in light contact with the skin and administer the light to each square cm 3. if the scanning technique is to be used, hold the tip of the probe within 1cm of the skin with the laser beam perpendicular to teh skin. administer the light to each square cm 4. ensure that the laser energy will not be directed into the patients eyes 5. if the patient reports anything unusual such as discomfrt at the tretement site, mausea, etc then discontinue treatment. 6. continue to monitor patient during the duration of the treatment -1 treatment per day only!

basic rules of stimulation electrodes

1. electrode should be wet ot have a conductive material associated 2. electrodes should be firmly attached 3.intensity should be adjusted after electrodes have been thoroughly secured 4.skin oil and hair will reduce electrode conductance 5.the larger the elctrode, the lesser the resistance 6. the circuit must be lcosed in order for current to flow form electrodes into the tissue

law of dubois reymond

1. stim of adequate amplitude to reach threshold of excitatory tissues 2. rate of voltage change (leading edge/ramping) must be rapid enough to avoid accomodation 3. length of stim or phase duration must overcome capacitance -needs to be enough electricity to make an immediate effect on the tissue -2 considerations for deciding how much electricity: amplitude and phase duration -similar to ultrasound -phase duration and amplitude detemines the change we get in the tissue

galvanic current

direct current (high volt stim) -monophasic

alternating current

normal and most often used current -bipahsic

peak amplitude

physiologic effects are produced

frequency

pulses/second