Modalities

Sensory Level EStim

* Large, superficial, cutaneous afferent fibers, below motor response - Targets A-b fibers - Comfortable stimulation * Usually first choice for pain control, only needed for acute pain * Electrodes in painful area Parameters: Frequency: 80-120 pps Pulse Duration: 80-120 μsec Amplitude: Sensory (Submotor) Modulation: 1 or more parameters Type of Current: balanced PC or MFAC Treatment time: Continuous for 15 to 20 minutes

Noxious Level EStim

* Primary goal is to produce noxious stimulation * Rarely used as first ES treatment approach * Used over motor, trigger, or acupuncture points Parameters: Frequency: DC or 1-4 pps Pulse Duration: none or >1msec Amplitude: until painful Modulation: not necessary Type of Current: DC or unbalanced PC Treatment time: 15-30 seconds per point

Motor level EStim

* Stimulates both sensory and motor nerves * Strong rhythmical muscle contraction * Primarily for chronic (non-acute) pain, may start with sensory-level trial and work to motor-level * Electrodes over motor point or motor nerve in area of pain Parameters: Frequency: <10 pps Pulse Duration: 200-300 μsec Amplitude: Motor Response Modulation: not required Type of Current: balanced PC or MFAC Treatment time: ~ 45 minutes -1 hour (until pain decreases)

Cryotherapy Indications

- Acute musculoskeletal trauma - Pain and muscle spasm, myofascial pain syndrome/trigger points - Delayed onset muscle soreness (possibly)

Cryotherapy Contraindications

- Cold sensitivity symptoms: * Cold uticaria, "ice allergy" * Cryoglobulinemia * Raynaud's Phenomenon * Paroxysmal cold hemoglobinuria - Not over areas of nerve regeneration - Not over areas of compromised circulation

Thermotherapy Energy Transfer Considerations

- Extent of tissue temperature increase desired (mild vs. vigorous) - Rate at which energy is added - Volume of tissue exposed - Type of tissue (and what layers are overlying) - Capacity of tissues to dissipate heat (related to blood supply)

Dosage for JM

- Grades I and II (pain relief) can be used daily (or as tolerated) - Grades III and IV (increasing mobility) should be used 3-5 non-consecutive days per week

Cryotherapy precautions

- Hypertensive patients - Generalized hypersensitivity to cold - Thermoregulatory disorders/difficulties - Areas of active wound healing - Superficial nerves (ulnar, common fibular)

Contraindications for JM/traction

- Inability to tolerate any movement (Grades I, II, III) - Inability to tolerate movement at end of ROM (Grades IV) - Untrained clinician! - Malignancy - Inflammatory arthritis - Bone disease - Neurologic involvement - Fracture - Congenital bone deformities - Vascular disorders of vertebral arteries (cervical spine)

Thermotherapy Precautions

- Medically unstable patient - Coronary heart disease - Muscle contusions - Respiratory distress - Bleeding disorders

Myofascial Release

- Method used to relieve soft-tissue and muscle from the "abnormal grip of tight fascia" - Stretching + tissue mobilization (applies force in 2 different directions) - Likely works via a neurobiological action 1. Activation of mechanoreceptors = gate control theory to break p! spasm cycle 2. Diffuse noxious input = activation of higher-level p! control mechanisms 3. Perturbation = tissue response = change in chemical messaging and altered response

Joint Traction Grades

- Neutralizes pressure in the joint, relieves pressure on WB surfaces = Grade 1 - Separates the joint surfaces by taking up slack in the joint capsule = Grade 2 - Lengthening of the soft tissues surrounding the joint = Grade 3 (typically combined with mobilization)

Joint Mobilization/traction Indications

- Reduction of pain - Decreasing muscle guarding and spasm - Lengthening of tissue surrounding a joint (capsule and/or ligament) - Facilitate muscle tone - Improvement of postural/kinesthetic awareness

Massage Methods

- Several varieties, most commonly Hoffa/traditional Principles: - Pressure is regulated based on type and amount of tissue - Contact should be maintained through out even if not apply pressure (keep hand on patient) - Rhythm must be steady and even, overlapping strokes - Typically pressure is applied parallel to tissue fibers and from distal to proximal - Swelling is an exception: start proximal then distal → proximal (uncorking effect) - Never painful

Maitland's Grades

- Small amplitude, beginning of ROM = Grade 1 - Larger amplitude, middle of ROM = Grade 2 - Larger amplitude, end of available ROM = Grade 3 - Small amplitude, end of available ROM = Grade 4 - Small amplitude (thrust), beyond available ROM = Grade 5 - Small amplitude = faster and smaller oscillations - 3-5 oscillation per second - Large amplitude = slower and larger oscillations - 2-3 oscillations per second

STM Contraindications

- UNTRAINED CLINICIAN - Open wounds - (Very) Immature wound healing (must start late proliferation/early maturation phase) - Concern for fracture - Malignancies - Cardiovascular risks (more of a precaution)

IASTM Rules

- tool should be held at a 30 to 60 degree angle to the surface - Flat side is on skin while beveled side is up - let tool weight do most of the work - follow/match or oppose the anatomy

Massage Applications

1. Application of emollient to aid sliding (shirt can serve as this) 2. Superficial, light and longer strokes (Effleurage) 3. Deeper, shorter strokes (Deep Tissue) 4. Deeper, focused kneading (Petrissage or Deep Tissue) 5. Work back to superficial strokes

Hemodynamic (blood change)

1. Arteriole vasoconstriction reduces bleeding 2. Decreased metabolism and vasoactive agents (inflammatory mediators - histamine, kinins, etc) reduces inflammation NERVE EFFECTS: 3. pain threshold is elevated - patient experiences less pain

Production of US wave

1. Electrical energy causes piezoelectric crystal to compress/expand (reverse piezoelectric effect) 2. Rapid compression/expansion produces a collimated beam of acoustic waves 3. Acoustic wave is transferred to US head 4. US head transfers wave to environment

Aspects of US Parameters

1. Frequency: 1 - 3MHz - 1 MHz * Deeper depth of penetration (up to 6cm) * Faster rate of attenuation - 3 MHz * More superficial depth of penetration (up to 2.5cm) * Slower rate of attenuation 2. Intensity: - Wave phase duration (*) wave amplitude = Magnitude of the acoustic energy - Expressed as W/cm2 3. Mode/Duty Cycle: - Continuous vs. Non-continuous/interrupted - Duty cycle options are typically 20, 50, and 100% 4. Treatment Area: - Important that treatment area is appropriate size to optimize heating (not too much, not too little) - 2-4x ERA of the sound head * Smaller = too intensive of heating = burns * Larger = not enough heating = waste of time 5. Type of tissue to be treated: - Amount of heating depends on density of tissue *Tendons/Ligaments have 2.5x faster rate and temperature rise than muscle

Positional Release Therapy Techniques

1. painful movement is identified 2. trainer finds tender point - applies pressure after locating 3. Trainer applies submaximal pressure to point 4. patient is moved by trainer into a position that minimizes tender point pain under trainer pressure 5. position and pressure is held for 90+ seconds 6. patient is moved back to neutral and point is reassessed for pain

Strain-Counter Strain Technique

1. painful movement is identified 2. trainer finds tender point - but does not apply pressure after location 3. patient is moved by trainer into a position that minimizes tender point pain 4. position is held for 90+ seconds - still no pressure on tender point 5. patient is moved back to neutral and point is reassessed for pain

In order to meet therapeutic levels, how high must tissue temperature be elevated?

104 to 113 degrees Less than 104 - won't feel a difference More than 113 - tissue breakdown and pain

When equipment manufacturers of electrical stimulation units determine preset pulse duration, they are based on the phase duration required to depolarize a nerve fiber when the amplitude is two times rheobase. What is the term associated with this phase duration? A. Chronaxie B. Motor depolarization potential C. Resting potential D. Electropiezo activity E. Interpulse interval

A. Chronaxie

Based on wavelength and frequency, which infrared modality is capable of achieving the greatest effective depth of penetration? A. Cold packs B. Hot whirlpool C. Paraffin bath D. Moist heat E. Cold whirlpool

A. Cold packs

An athletic trainer is treating an athlete with shortwave diathermy using a drum electrode. The drum electrode has been placed 6 inches from the athlete's low back. Based on the inverse square law, how would the intensity alter if the drum is moved to a position 3 inches from the treatment area? A. Intensity at the new position will be 1/9 of full intensity. B. The intensity of the original position will be 1/12 of full intensity. C. The intensity will decrease by 1/2 as the drum is moved from the original position to the new position. D. The intensity will increase by 1/2 as the drum is moved from the original position to the new position. E. The intensity will increase by 1/9 as the drum is moved from the original position to the new position

A. Intensity at the new position will be 1/9 of full intensity.

Your treatment goal is to increase tissue temperature by 2°C in the piriformis muscle. Which therapeutic modality, whose wavelengths are within the electromagnetic spectrum, is capable of achieving this treatment goal? A. Microwave diathermy B. Ultrasound C. Moist hot pack D. Warm whirlpool E. Ultraviolet

A. Microwave diathermy

You are treating an athlete with a subacute ankle sprain who has been receiving only cryotherapy. You choose to employ a contrast bath as a transitional modality. Which of the following is a physiological effect of a contrast bath? A. Only a superficial capillary response B. Constriction of deep blood vessels with ice immersion C. Dilation of deep blood vessels in response to heating D. A vascular pumping action to effectively remove swelling E. A cumulative tissue temperature increase is achieved

A. Only a superficial capillary response

An athlete presents to the athletic training room complaining of left-sided low back pain and left leg radicular pain. The athlete is assuming a right lateral flexed posture. In which position should the athlete be placed to treat with positional traction? A. Side-lying on a towel roll with left side up B. Side-lying on a towel roll with right side up C. Supine with both knees held tightly to the chest D. Supine with hips and knees supported in a 90/90 position E. Prone with bolster placed bilaterally under the ASIS's

A. Side-lying on a towel roll with left side up

Which of the following statements best describes a typical mechanical cervical traction protocol? A. The athlete is supine or long-sitting with the neck flexed between 20° and 30°, and a traction force greater than 20 lb is applied intermittently. B. The athlete is prone with the neck in a neutral position, and a traction force of 20 lb is applied continuously. C. The athlete is long-sitting with the neck extended 20°, and a traction force of 15 lb is applied intermittently. D. The athlete is supine with the neck in a neutral position, and a traction force of 5% of body weight is applied continuously. E. The athlete is prone with the neck flexed 10° to 20°,and a traction force greater than 10 lb is applied continuously

A. The athlete is supine or long-sitting with the neck flexed between 20° and 30°, and a traction force greater than 20 lb is applied intermittently.

What is the propose of a coupling medium when completing an ultrasound treatment? A. To provide a conduit for the sound waves B. To minimize the athlete's potential adverse reaction to sound-wave transmission C. To reduce the uncomfortable sensation associated with sound-wave absorption D. To minimizes risk of accumulating harmful rebound waves E. To minimize deflection of the energy by the skin

A. To provide a conduit for the sound waves

Burst Medium Frequency

AKA "Russian Current" Typical Protocol: - Carrier frequency: 2500pps - 50 bursts/second - 10 seconds on, 50 seconds off (duty cycle) For muscle contraction!

Interfered Medium Frequency

AKA: Interferential Current 2 channels, each with a carrier frequency - typically one channel at 4000pps and second channel at 4001 to 4150pps Electrodes set-up so two channels intersect Difference between 2 carrier frequencies creates a beat where they intersect For pain modulation!

Physical Principles of US

Acoustic energy that exert mechanical action by vibrating molecules into adjacent molecules - Cannot be applied across very low-density molecular structures * Must be applied using a coupling medium (gel, cant use air) When change in molecular density is encountered - Reflection * bending/change of direction back (don't want) - Refraction * bending/change of direction in new tissue (minimize it) - Absorption * acoustic energy transforms to thermal energy (attenuation) (we want THIS)

Soft Tissue Mobilization Goal

Aims to optimize or restore soft-tissue functioning

Alternating Current (AC)

Alternating polarity - no polarity effects Frequency range - low <1000 pps - medium 1000-10,000 pps - High > 10,000 pps (diathermy) Pulse duration inversely related to frequency (as frequency increases, pulse duration decreases) Typically we will be in low or medium range

Which method of heat transfer is applied when an athlete uses a warm whirlpool to heat the lower extremity? A. Conduction B. Convection C. Radiation D. Conversion E. Evaporation

B. Convection

In which of the following ways does cold application best address the inflammatory phase of the healing process? A. Decreases swelling in the injured area B. Decreases the cell's metabolic need for oxygen C. Decreases the viscosity of fluids in the injured area D. Decreases the amount of hemorrhage that occurs E. Decreases the extensibility of associated tissues to enhance stability

B. Decreases the cell's metabolic need for oxygen

You are treating a hamstring muscle belly strain. Your treatment goal is to increase tissue temperature of the affected muscle. The treatment mea is approximately 8" x 20". Which of the following methods would best assist in achieving this treatment goal? A. Two hot packs side by side to effectively cover the area B. Dividing the area in half and doing two identical continuous ultrasound treatments C. Continuous ultrasound treatment at an intensity twice that used for a smaller treatment area D.Warm whirlpool at a temperature of 98°F to 108°F E. Two hot packs one on top of the other placed over the belly of the muscle

B. Dividing the area in half and doing two identical continuous ultrasound treatments

Which of the following responses are associated with the reflexive effects of therapeutic massage? A. Elimination of toxins, sedation, and shift in acid-base equilibrium of blood B. Increased capillary permeability, pain control, and no significant alterations in general metabolism C. Decreased cellular metabolism, increased dispersion of waste products, and release of B-endorphins and enkephalins D. Increased fibroplasia, increase in blood volume and blood flow, and increase in tissue temperature E. Central pooling of blood, decreased resting heart rate, and retardation of muscle atrophy

B. Increased capillary permeability, pain control, and no significant alterations in general metabolism

A tennis player reports to the athletic training room with palpable pain over the common origin of the wrist extensors. There is no obvious swelling or redness, although the area is warm to the touch. Passive wrist flexion and resisted wrist extension increase pain. Which therapeutic modality is contraindicated in the treatment of this athlete? A. Ice bag B. Moist hot pack C. Iontopholesis D. Electrical stimulation E. Pulsed ultrasound

B. Moist hot pack

An athletic trainer is utilizing motor level stimulation to promote muscle re-education. Where should the active electrode be placed to facilitate this treatment? A. At least 6 inches from the dispersive electrode and over the muscle belly B. Over the motor point C. Over an active trigger point D. No more than 6 inches from the dispersive electrode E. Any soft-tissue area outside the electrical field

B. Over the motor point

Which nonthermal effect of ultrasound is most associated with low-frequency, high-intensity sound waves and is believed to result in tissue damage? A. Stable cavitation B. Unstable cavitation C. Stable acoustical streaming D. Unstable acoustical streaming E. Acoustical microstreaming

B. Unstable cavitation

During the course of treating an athlete using lumbar positional traction, you note that the athlete is receiving only partial relief of symptoms. What steps can you take to improve the athlete's outcome for this treatment? A. While lying supine, bring the athlete's left knee to the opposite shoulder; repeat on the opposite side. B. While side-lying, flex the athlete's hips maximally,and rotate the top shoulder posteriorly. C. While lying prone, press the athlete up onto forearms, and rotate torso, lifting one hand toward the ceiling. D. While side-lying, flex the athlete's knee, and maximally extend hips. E. While lying prone, extend the athlete's opposite arm and leg while the athlete is looking upward toward the ceiling

B. While side-lying, flex the athlete's hips maximally,and rotate the top shoulder posteriorly.

Which of the following athletes would benefit from ultraviolet therapy? A. A sprinter with diabetes B. A wrestler with herpes simplex C. A field hockey player with chronic psoriasis D. A linebacker taking tetracycline E. A swimmer with lupus erythematosus

C. A field hockey player with chronic psoriasis

Which of the following ale commonly accepted physiological responses to superficial heat application? A. Decreased viscosity, increased tissue elasticity, and decreased inflammation B. Anesthetic effects, increased phagocytosis, and increased lymphatic drainage C. Analgesia, increased metabolic activity, and increased inflammation D. Decreased antibodies, increased axon reflex, and decreased muscle spasm E. Increased capillary permeability, increased edema formation, and decreased metabolic wastes

C. Analgesia, increased metabolic activity, and increased inflammation

A clinician is using Hoffa massage to treat a musculoskeletal disorder, Which stroke type should be utilized if the goal is to accustom the athlete to the physical contact of the clinician? A. Petrissage B. Tapotement C. Effleurage D. Vibration E. Percussion

C. Effleurage

What causes the ultrasound transducer crystal to vibrate and create sound waves? A. It is mechanically oscillated by the electrical current. B. It is chemically stimulated by the electrical current. C. It expands and contracts due to the alternating polarity of the electrical current. D. It becomes part of the athlete's electrical field. E. It utilizes mechanical deformation to produce electrical voltage

C. It expands and contracts due to the alternating polarity of the electrical current.

For which of the following treatment goals is transcutaneous electrical nerve stimulation an acceptable modality? A. Enhance movement from inflammatory to repair phase of healing B. Decrease pitting edema and enhance lymphatic drainage C. Manage athlete's chronic pain D. Minimize excess scar tissue formation E. Increase range of motion and tissue extensibility

C. Manage athlete's chronic pain

Which of the following statements best illustrates the relationship between wavelength, frequency, and depth of penetration as it applies to modalities? A. There is a direct relationship between frequency and depth of penetration. B. There is a direct relationship between wavelength and frequency. C. There is an inverse relationship between wavelength and frequency. D. There is an inverse relationship between wavelength and depth of penetration. E. There is an equal relationship between wavelength and frequency.

C. There is an inverse relationship between wavelength and frequency.

Medium Frequency (MFAC)

Carrier Frequency(CF) - Initial frequency set in machine - 2500 to 5000 pps is typical range Two typical ways to manipulate the carrier frequency -burst the CF of one channel - interfere the CF of 2 channels

Patient response to cryotherapy

Co-BAN 1. Cold 2. Burning 3. Achy 4. Numbness Each one should take 2 minutes - if longer, then discontinue

Application of Laser

Color/wavelength --> treatment goal Red (400-700nm) shorter, Less penetration --> Reduction of inflammation and Reduction of pain Blue/Green (700-1,200nm) Deeper penetration --> tissue healing

Conduction

Contact between surfaces

Convex-Concave Rule

Convex moving on concave = glide will oppose roll (knee)(ROCO - round on cup opposed) Concave moving on convex = glide will follow roll (ankle) (CORS - cup on round same)

Prior to completing glade IV joint mobilizations, an athletic trainer chooses to use ultrasound to create vigorous tissue heating to stretch collagen. What degree of tissue temperature increase is required to achieve this treatment goal? A. I°C B. 2°C C. 3° D. 4°C E. 5°C

D. 4°C

What factors should be considered when calculating ultrasound treatment time? A. Intensity, coupling medium, frequency, and fat percentage of treated tissue B. Effective radiating area of the sound head, duty cycle, and desired tissue temperature change C. Resting tissue temperature, size of treatment area, output, and coupling medium D. Frequency, output, duty cycle, and desired tissue temperature change E. Density of treatment tissue, hydration status of athlete, duty cycle, and speed of transducer movement

D. Frequency, output, duty cycle, and desired tissue temperature change

You are using a bipolar electrode placement technique for muscle re-education of the quadriceps muscle group. Two equally sized electrodes are placed in series along the direction of the muscle fibels. If this setup fails to achieve a maximal muscle contraction, what is the most appropriate alteration? A. Place one large electrode over the muscle fibers and a small electrode out of the treatment area. B. Increase the current fiequency. C. Increase the intensity. D. Increase the space between the electrodes. E. Use a more aqueous conduction medium under the electrodes.

D. Increase the space between the electrodes

Which therapeutic modality's wavelength places it between infrared and ultraviolet on the electromagnetic spectrum? A. Microwave diathermy B. Shortwave diathermy C. Electromyographic biofeedback D. Laser E. Electrical stimulation

D. Laser

When treating a wrist injury with a warm whirlpool, what is the maximum recommended water temperature in degrees Fahrenheit? A. 98°F B. 106°F C. ll0°F D. lI2°F E. 120°F

D. lI2°F

STM Indications

Decreased ROM - If limited by accessory joint motions = myofascial release + joint mobilization/traction - If limited by pain = myofascial release or massage Swelling/Excessive Edema - Massage, IASTM Optimization of collagen healing/tissue alignment - joint mobilization(grade 1 or 2)/traction, IASTM Excessive scaring (keloid or hypertrophic scar) - IASTM, massage

Types of Electrical Currents

Direct (DC): Unidirectional flow of current (-) or (+); Polarity remains constant for atleast 1 second Alternating (AC): Uninterrupted flow of current that alternates Pulsatile (PC): Interrupted flow of current (monophasic, biphasic, or polyphasic)

Fol which of the following athletes would massage be contraindicated? A. An athlete with chronic biceps tendonitis who plesents with limited range of motion B. An athlete who is 2 weeks status post anterior cruciate ligament reconstruction who presents with normally healing scar tissue C. An athlete who is 2 days post forearm cast removal who presents with muscle atrophy D. An athlete with chronic bilateral paraspinal muscle spasm secondary to a partially herniated vertebral disc E. An athlete who is 4 days status post second-degree ankle sprain who presents with tight, red, shiny skin

E. An athlete who is 4 days status post second-degree ankle sprain who presents with tight, red, shiny skin

Which of the following theories of pain management is most likely employed when an athletic trainer utilizes massage to stimulate myofascial trigger points? A. Gate control theory B. Gate control theory with endogenous opioid analogue C. Central biasing D. Cognitive influence E. B-endorphin and enkephalin release

E. B-endorphin and enkephalin release

With respect to therapeutic ultrasound, what is the stretching window? A. Minimal number of minutes that tissue should be stretched following an ultrasound treatment B. Theoretical time interval between cessation of an ultrasound treatment and initiation of a stretching protocol C. Minimal number of minutes between onset of ultra-sound treatment and achievement of maximal tissue heating D. Theoretical period following a stretching session before a second ultrasound treatment can be initiated E. Theoretical period of vigorous heating when tissues will undergo the greatest extensibility and elongation

E. Theoretical period of vigorous heating when tissues will undergo the greatest extensibility and elongation

The physiological effects of which of the following therapeutic modalities would assist in overcoming the method by which oxygen tension impedes healing? A. Cryotherapy B. Pulsed ultrasound C. Transcutaneous electrical nerve stimulation D. Iontophoresis E. Thermotherapy

E. Thermotherapy

Following a superficial heat application, the athlete demonstrates spotty reddening of the treated area. What is the correct term for this physiological response? A. Allergic reaction to the modality equipment contacting the skin B. Tissue ischemia secondary to Hunting's response C. Heat urticaria secondary to increased blood flow D. Tissue hyperhydrosis secondary to increased metabolism E. Tissue mottling secondary to an excessive local histamine release

E. Tissue mottling secondary to an excessive local histamine release

Goals of US

Effect desired ---> net temp increase Non-thermal --> None Mild thermal --> 1 degree Mod thermal --> 2-3 degrees Vigorous --> 4 degrees

Physical Properties of photobiomodulation (light) Therapy

Electromagnetic wave = energy propagated through space -Transports electrical and magnetic energy - Does not require a medium in order to travel - Can be reflected, refracted and absorbed

EStim for Strengthening

For "weak" muscles post surgery/trauma/immobilization Parameters: Frequency: 50-80 pps Pulse Duration: .3+ msec Amplitude: % MVIC (35-60%) Duty Cycle: 1:5 (10 ON, 50 OFF) progress to less off time Ramps: on and off for comfort (consider total on time) Type of Current: PC or MFAC Treatment time: # of reps to fatigue (8-15) Treatment visits: 3-5x/wk for 3-4 weeks

EStim for Re-Education

For CNS impairment or Post-trauma/post-surgery Incorporate into other treatments/exercises/functional activities - Patient assists, attempts to perform movement during stimulation Parameters: Frequency: 30 pps Pulse Duration: .1-.3 msec Amplitude: to desired motor response Duty Cycle: 1:3 Ramps: on and off for comfort (consider total on time) Type of Current: PC or MFAC Treatment time: 10-30 minutes - 3x/week

EStim for Orthotic Substitution

For dorsiflexion assist - "re-ed's" neuromuscular function - Promotes normal gait pattern Parameters (for DF assist): Frequency: 30 pps •Pulse Duration: .1-.3 msec Amplitude: movement through DF/EV Duty Cycle: heel switch Ramps: None Type of Current: PC (small portable unit) Treatment time: long-term while ambulating

EStim for Pain Control (theories)

Gate Control - "Close the gate" from below Endorphin release - Stimulate the release of endorphins Central Biasing - Cause pain inhibition "close the gate" from above Breaking pain-spasm cycle - Change sensitivity of nociceptors/free nerve endings

When tissue temp is 50 degrees or less - what response may occur?

Hunting Response (cold-induced vasodilation)

EStim Precautions

Hypersensitivity to ES Allergic reaction to adhesive electrodes

Laser Precautions

Impaired sensation Indirect eye exposure

US Intensities to Tissue Temp Increases

Intensity-1MHz-3MHz 0.5 - 0.04 de - 0.3 de 1.0 - 0.2 de - 0.6 de 1.5 - 0.3 de - 0.9 de 2.0 - 0.4 de - 1.4 de *degree increases per minute*

Types of Light Therapies

Light Amplification by Stimulated Emission of Radiation (laser) - Low-level laser therapy (LLLT), "cold laser" - High-intensity level therapy (HILT)(this gets warm) Light-emitting diodes (LED) Supraluminous light-emitting diodes (SLED)

Joint Mobilization techniques

Maitland - mobilization should target direction of restriction (tissue structure approach) Mulligan - any mobilization will work, often combined with movement, "mobilizations with movement" (neurological approach)

Thermotherapy (biophysical) Properties

Metabolic Effects: - Metabolic activity of cells demonstrate 2-3x increase for every 50 degree increase - Mild Inflammatory reaction *Clinical application - this will cause swelling - don't put it on someone in the inflammation phase already* Vascular Effects: - Vasodilation and increased blood flow Neuromuscular Effects: - Reduce pain and resolve pain-spasm cycle Connective Tissue Effects: - Increase tissue elasticity and decrease tissue viscosity (aka decrease joint stiffness and increase tissue extensibility/flexibility)

Electrode Configurations

Monopolar (2+ unequal sized pads) - required when polarity desired (Iontophoresis or wound healing) Bipolar (equal sized pads) - Ex TENS Quadripolar (four same sized pads) - Often IFC

Does it take more time for people to warm up or cool off?

More time to warm

Pulsed Current (PC)

Most common of the machines used Pulse duration independent of frequency Can be monophasic - Polarity effects (negative for depolarization) - Unique type = high volt pulsed current (HVPC) Can be biphasic - Symmetrical vs. asymmetrical - Balanced vs. unbalanced (polarity effects)

ST methods/techniques

Myofascial Release - Foam rolling - Manual - Active Release Therapy® (ART) - Strain-Counter Strain - Positional Release Therapy (PRT) Instrument Assisted Soft-Tissue Mobilization - Graston® Massage

Direct Current (DC)

No frequency - "one long pulse" = one action potential when current first delivered - Not good for multiple AP's for sensory or motor response Polarity effects - Good for iontophoresis or wound healing - Must be cautious with duration

What type of pain control is active release therapy?

Noxious Level 1. Trainer finds knot in muscle 2. Trainer traps (or pins down) knot 3. Patient contract/relax while pressure is held

What position do you want the joint in prior to beginning mobilizations?

Open-packed position

EStim Contraindications

Pacemakers Electronic monitoring anterior neck transthoracic area pregnancy area of DVT cancerous area sensory or mental impairments

JM Indications to Grade

Pain --> Grade I, II Decreasing muscle guarding and spasm --> Grade I or II (to break pain-spasm cycle) Restricted ROM due to contraction of tissue (after pain and spasm have been resolved) --> Grade III or IV Facilitate muscle tone --> Grade I, II Improvement of postural/kinesthetic awareness --> Grade I, II

US Precautions

Plastic or cement implants Spinal cord Superficial nerves

US Contraindications

Pregnancy (abdomen or low back) Active bone growth at epiphysis Cancer TB infection Hemorrhagic conditions Impaired circulation, sensation, and/or cognition/communication Myositis ossificans DVT or thrombophlebitis Acute injury/active inflammation Areas of recent radiation treatment Skin disease ICDs, other implanted devices Reproductive organs, eyes, anterior neck

Pre-Mod IFC EStim

Premise: two medium-frequency currents crossed inside the machine - Only two electrodes needed In reality - Time-modulated AC - Medium frequency delivered with interruptions at set times so that bursts of current exist Sensory level EStim

Purposes/indications of EStim

Re-education Strengthening Orthotic substitution Pain control Muscle spasm Edema reduction

Thermotherapy Indications

Reduction of pain Reduction of stiffness Reduction of muscle spasm Increase ROM Improve tissue healing (in a subacute phase)

ES for PC Types

Sensory-level (conventional, high-rate, modulated): - Gate Theory Motor-level (low rate, burst) - Endorphin release (consider medications) - Break pain-spasm cycle Noxious-level (hyperstimulation, brief intense) - Central Biasing - Endorphin release (consider medication)

Parameters for laser

Shorter wavelengths (<633) = superficial depth of penetration (<0.5cm) Longer wavelengths (>700) = Deeper depth of penetration (2-4cm) Treatment dosage = J/cm2 Continuous vs. Pulsed

Laser Contraindications

Should not be applied in: - Direct eye exposure - Active malignancy - Active hemorrhage - Open growth plates - Endocrine glands (anterior neck) Should not be applied in the presence of: - Pregnancy

Thermotherapy Contraindications

Should not be applied over areas of: - Decreased thermal sensation - Vascular insufficiency - Recent hemorrhage or potential - Known malignancy - Acute inflammation - Infected areas - Recently applied liniments/heat rubs

IFC EStim

Simultaneous application of two medium frequency currents - Typical carrier frequency: 4000-5000 pps * Phase duration: 100-125 ms Sensory level EStim

Thermotherapy principles (conductive)

Skin: - Greatest temp change at 0.5 to 2cm deep - will reach peak within 6 to 8 minutes Muscle: - Greatest temp change at 1 to 2cm deep (> 3cm will have non therapeutic increase) - wont reach peak until 15+ mins Intra-articular: - Must be superficial (have little to no overlying soft tissue) - Everything other than fingers/toes will be too deep to reach Soft tissues: - Mild heating, 104 degrees = soothing, counter irritant effect - if need for higher temperature increase, choose different method

arthrokinematic movements

Spin: pure rotation (one point on one surface maintains contact with one point on the other surface)(pivot) - pivot or ball and socket joints Roll: series of points on one surface comes in contact with a series of points on the other surface (rocking chair) - tibiofemoral, thumb Glide: a point on one surface moves across a series of points on the other joint surface. (computer mouse) - tibiofemoral

joint mobilization

Techniques that aim to restore pain-free ROM by restoring accessory joint motions (arthrokinematics)

High Volt EStim

Two required parameters - Must transmit at least 150V - Must use twin-peaked, monophasic current * Deeper penetration * Increased comfort

What happens when cold is applied?

Vasoconstriction (amount of warm blood to the area is decreased)

Whirlpool vs Immersion

Whirlpool temp: 50-60 degrees Immersion temp: 40-50 degrees Whirlpool FEELS colder because you can't develop the thermopane

US Indications

Wound Healing Arthritis Increasing tissue elasticity Nonspecific shoulder p! Bursitis Myofascial trigger points Low back pain Carpal Tunnel Syndrome (p!) Calcific tendinitis

Radiation

conversion of energy via electromagnetic waves/fields

Convection

moving fluid/air between surfaces

Evaporation

phase change requires energy