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CHIROPRACTIC PHYSIOLOGICAL THERAPEUTICS FOR THE CHIROPRACTIC ASSISTANT DR. RONALD GRANT Associate Professor Basic Science & Chiropractic Departments Former Chief of Staff of LHC Private Practice 34 years Offices located at Lutheran Hospital, Creve Coeur Surgery Center & Chesterfield, MO. (At Logan College) Specialize in MUA & Family Practice CHIROPRACTIC PHYSIOLOGICAL THERAPEUTICS The Council on Physiological Therapeutics of the ACA defines chiropractic physiotherapy as the therapeutic application of forces and substances that induce a physiologic response and use and/or allow the body’s natural processes to return to a more normal state of health. 3 PHYSIOLOGICAL THERAPEUTICS The primary intent of Chiropractic Physiological Therapeutics is to assist the body in adapting to and/or normalizing the aberrant processes within an abnormal state. 4 PHYSIOLOGICAL THERAPEUTICS Chiropractic Physiological Therapeutics encompasses the diagnosis and treatment of disorders of the body, utilizing the natural forces of healing such as cold, electricity, exercise, traction, heat, light massage, and water. 5 PATIENT PRESENTATION Patients present to the doctor with myriad of problems and a variety of conditions, both physical and emotional. Some patients present with problems and conditions that are easily identified and provide the doctor with a clear clinical picture. 6 OBVIOUS SIGNS AND SYMPTOMS Other patients present with problems that may not be as easily identified. The patient with a more severe injury may present with so much inflammation and pain that a complete examination may be difficult to perform. Initial treatment may require attention directed at the signs and symptoms. 7 OBVIOUS SIGNS AND SYMPTOMS As the condition improves in response to therapy, however, a clearer picture usually develops and a specific diagnosis determined. 8 TREATMENT SELECTION The choice of which treatment is most appropriate for any given condition varies from patient to patient. Therapy that is effective for one patient may not necessarily be helpful for another who is suffering from a similar disorder. Likewise, the choice of which treatment to use for a given patient varies from 9 clinician to clinician. TREATMENT SELECTION Saunders (1985) claims that doctors tend to select treatment based on their individual training and philosophy rather than what is necessarily best for the patient. 10 TREATMENT CONSIDERATIONS AND METHODS When developing a therapeutic plan of action, thought must be given to the nature of the treatment itself. Treatment that is physically demanding or that places excessive financial demands on patient’s may not be in their best interest. 11 TREATMENT GOALS AND PLAN OF CARE Whenever a clinician attempts to establish a treatment plan, attempts must be made to set reasonable and attainable therapeutic goals for the patient. If the treatment is to be effective, the patient and the clinician must agree on the goals and the process involved in achieving them. 12 TREATMENT GOALS AND PLAN OF CARE Patients should understand what the treatment entails and what outcome to anticipate. It is necessary to develop a clear therapeutic plan of action. As treatment ensues, the plan should be evaluated and modified accordingly. 13 Placebo Effect of Physiological Therapeutics There is a major placebo effect in all that we do in providing any therapy to our patients. This placebo effect is a basic and extremely important tool to help us achieve the best results. Our attitude toward the patients and our presentation of the therapy is crucial. Placebo Effect of Physiological Therapeutics When the Chiropractic Assistant demonstrates a sincere interest in the patient’s problems, the patient uses that interest to add to his or her own conviction and motivation to get well. When these factors are active, real physiologic changes occur that assist in the healing process. Placebo Effect of Physiological Therapeutics The CA should not intentionally deceive the patient with a sham treatment but should use the treatment to have the best impact on the patient’s perception of the problem and the treatment’s effectiveness. Placebo Effect of Physiological Therapeutics The treatment will work better if the patient has a profound belief in the treatment’s abilty to alleviate the problem. To gain the most from this effect, the patient needs to be intimately involved with the treatment. We must educate, encourage, and empower the patient to get better. Placebo Effect of Physiological Therapeutics Giving the patient the knowledge and ability to feel some control and to be self-determined in healing reduces the stress of injury and enhances the patient’s recovery powers. Placebo Effect of Physiological Therapeutics In stressful situations any measure of control lessens the extent of the stress and results in the improvement of disease resistance or injury recovery factors that will improve treatment outcomes. INDICATIONS AND CONTRAINDICATIONS Each treatment procedure may be used more effectively and safely in some patients than in others. One of the factors that must be stressed is the presence of specific indications for the treatment. In addition, any factors that either contraindicate a specific treatment or call for precautions when applying 20 treatment must be recognized. INDICATIONS AND CONTRAINDICATIONS Absolute contraindications - some treatments should absolutely not be attempted in the presence of these factors; for instance the use of shortwave diathermy in a pregnant patient in which the risk of harm to the fetus outweighs any potential benefit to the mother. 21 INFORMED CONSENT In addition to clinical considerations, each patient has the right to informed consent prior to the initiation of any examination or treatment procedure. 22 PASSIVE VS. ACTIVE Passive therapy includes those treatment modalities that do not require any energy expenditure on the part of the patient. Rather the modality is applied to the patient while he or she lies quietly on the therapy table. These modalities include massage, heat and cold, EMS, US, Traction and so forth. 23 PASSIVE VS. ACTIVE Active therapy, unlike passive therapy, demands some active involvement on the part of the patient. Among the active therapeutic modalities are exercise, education, retraining, and work hardening. Current evidence and treatment trends are focusing more attention on active forms of therapy. 24 PASSIVE MODALITIES GOALS The following modalities are principally effective during the early phases of treatment: Relief of pain (e.g.., TENS, US, Ice, Heat) Reduction of swelling and edema (e.g.., EMS, US and Ice) Reduction of muscle tension (e.g.., EMS, Heat, Massage) 25 PASSIVE MODALITIES GOALS Promotion of tissue healing (e.g.., EMS, Microcurrent, US) Improvement of circulation (e.g.., EMS, Heat, US) 26 GOALS DURING CHRONIC PHASE Relief of pain (e.g.., TENS, US, Heat) Reduction of muscle tension (e.g.., EMS, Heat, Massage) Reduction of fibrous tissue and adhesions (e.g.., EMS, US, Massage) Improvement of ROM (e.g.., EMS, US) 27 BASIC FORMS OF THERAPEUTIC APPLICATIONS 1. Thermotherapy A . Hot moist packs * B . Infrared C. Heating pads D. Ultraviolet E . Paraffin * F . Fluidotherapy BASIC FORMS 2. Cryotherapy A . Ice * B . Cold packs * C. Vapocoolant sprays * D. Clay compresses E . Cold immersions * F . Cryokinetics * G. Contrast therapy * BASIC FORMS 3. Diathermy * A . Short-wave * . Induction or coil field . Condenser field B . Microwave * C. Ultrasound * BASIC FORMS 4. Interferential current * 5. Low frequency currents * 1. 6. Direct current (Galvanic) High Voltage current * 1. 2. 3. 4. Alternating current Sine wave Faradic current TENS 5. Muscle stimulators BASIC FORMS 7. Hydrotherapy * 8. Exercise therapy 9. Rehabilitative therapy 10.Meridian therapy A . Pressure techniques B . Acupuncture C. Auricular therapy D. Ryodoraku E . Laser BASIC FORMS 11.Vibratory therapy * 12.Traction and stretching 13.Bracing and supports GENERAL CONSIDERATIONS 1. Preparation of the patient A . Check the following data: .Diagnosis .Correct area .Correct modality and usage .Contraindications .Special instructions .Vital signs GENERAL CONSIDERATIONS B . Determine the procedure to be used .Type of modality (Doctor will choose) . Method of application . Patient position . Timing GENERAL CONSIDERATIONS .Check the unit’s use and operation: 1 . How it works 2 . How to explain how it works 3 . Know how to use it. 4 . Be sure it is working properly 5 . Check the connections GENERAL CONSIDERATIONS 2. Starting the treatment A . Know exactly what you are doing and how to do it. B . Act with confidence C. Explain the procedure to the patient D. Position the patient carefully E . Inspect the patient F . Start the treatment G. Monitor the patient frequently GENERAL CONSIDERATIONS 3. Terminating the treatment . First: remove electrodes from the patient B . Turn off the unit C. Dry and check the patient’s skin D. Check the patient for dizziness, nausea, and faintness E . Ready the patient for the adjustment GENERAL CONSIDERATIONS 4. Precautions and complications: Immediately note any signs of burns or any other problems and take appropriate action. 5. Schedule the patient’s next appointment PATIENT POSITIONING The positioning of a patient prior to the application of a physical agent mdality is one of the most important aspects contributing to a successful treatment. Placing the patient in an aligned and supported position insures muscular relaxation and facilitates venous flow of blood. GENERAL RULES Be sure you know what your confronted with (i.e..; symptoms, conditions, pathophysiology involved). Choosing (doctor) a modality that is best suited for the presenting complaint. Guard against insufficient or excessive treatment. Intervals of long duration between treatment will result in failure. GENERAL RULES Don’t “overtreat” with certain modalities Explain to the patient what to expect; (long term results, temporary results, the anticipated number of treatments necessary, etc.) P.T. OBJECTIVES Increasing and maintaining strength and endurance Increasing coordination Decreasing pain Decreasing muscle spasm Decreasing swelling P.T. OBJECTIVES Decreasing chest congestion Correcting postural deviations Promoting the healing of soft tissue lesions Preventing contractures and deformities Increasing range of motion in joints SUPERFICIAL HEAT THERAPIES Hot moist heat Paraffin dips Whirlpool Short-wave & Microwave diathermy HOT MOIST HEAT HYDROCOLLATOR 46 HOT MOIST HEAT This is the most commonly used heat modality Transfers heat to the patient primarily by conduction Most common cause for malpractice in physiotherapy today is burns, and they are most frequently caused by hot packs. 47 HOT MOIST HEAT The moist packs should be totally submerged in water to a minimum of 30 to 40 minutes between use to regain their correct temperature (150 -180 degrees F) 48 49 HYDROCOLLATOR TANK 51 Patient Protection Position six layers of toweling, which equals I inch of toweling, so that the hot pack can be covered sufficiently. Sufficient toweling should be placed so that it protects the patient from burns. Considerations The size of the body segment to be treated should determine how many packs are needed. Time of application should be 15 to 20 minutes. 54 HOT MOIST HEAT Hot moist heat can be used in conjunction with other therapies. Moist heat vs. dry heat: dry heat causes stiffness (forces blood away from the cutaneous capillary bed) 55 HOT MOIST HEAT EFFECTS Increased circulation to the area being treated. Muscle temperature is increased. Relaxation Decreased pain Decreased muscle spasm Generalized effect (PR, BP) 56 TREATMENT CONSIDERATIONS The size of the body segment to be treated should determine how many packs are needed. Patient comfort is always a consideration Time of application should be 15 to 20 minutes and monitored every 3-5 minutes. 57 TREATMENT CONSIDERATIONS If the target tissue is deeper than 1 cm (e.g., the spinal facet joints), a hot pack will not be effective. Other joints, such as the knee, wrist, and ankle, can be effectively heated with a hot pack. HOT MOIST HEAT Always have patient inform you if hot pack is too hot. Do not use steam packs over cuts or abrasions. Do not use heat packs in conjunction with skin balm or liniments. Do not use toweling that is moist from use. Patients should not lie on the hot packs59 INDICATIONS Non-acute sprains/strains Sinus conditions Menstrual cramps Arthritis, tendinitis, bursitis, capsulitis Decreasing pain before exercise As a preliminary treatment to other modalities. 60 CONTRAINDICATIONS Acute conditions Patients on anti-coagulants Psychological hysteria or drug dependent Dermatological conditions Diabetic or alcoholic neuropathy Severe vascular occlusions Tumors 61 PARAFFIN THERAPY DR. GRANT 62 PARAFFIN BATH Paraffin bath is a simple and efficient, though somewhat messy, technique for applying a fairly high degree of localized heat. Paraffin treatments provide six times the amount of heat available in water because the mineral oil in the paraffin lowers the melting point of the paraffin. 63 PARAFFIN BATH The combination of paraffin and mineral oil has a low specific heat, which enhances the patient’s ability to tolerate heat from paraffin better than from water of the same temperature. The risk of a burn with paraffin is substantial. 64 PARAFFIN THERAPY Paraffin is essentially hot wax that consists of seven parts paraffin and one part mineral oil. (7:1 ratio) Some authorities recommend a 4:1 ratio 65 PARAFFIN THERAPY Purpose of the mineral oil is to lower the melting temperature of the wax. Without the mineral oil, the melted wax would be far too hot for therapeutic purposes. 66 PARAFFIN THERAPY Because the paraffin-oil mixture has a low specific heat, it can be applied directly to the skin if the circulation to the part is normal. 67 68 69 70 PARAFFIN THERAPY Before the application, the part to be treated should be cleaned and dried, the thermesthetic sense should be ascertained to be normal, and all jewelry on the part to be treated should be removed. 71 PARAFFIN THERAPY Temperature of the melted wax should be checked with a thermometer, but a finger pre-test by the doctor/therapist will even more assure the apprehensive patient that the mixture is not too hot. Paraffin offers the same effects and advantages as any other form of superficial heat that is transferred by conduction , such as increase in tissue temperature and pain relief. 72 PARAFFIN THERAPY INDICATIONS Primarily indicated for non-acute arthritic joints, especially where there is limited mobility. Bursitis, post fractures, stiffness, sprains, strains, and indurated scar tissue or contractures that limit motion 73 PARAFFIN THERAPY CONTRAINDICATIONS Paraffin should not be used over open wounds, abrasions, acute skin disorders, or where their is diminished sensation. 74 METHODS OF PARAFFIN THERAPY APPLICATIONS When constant heat is required for a long period, two or three hours, the application of the paraffin boot, properly insulated, gives excellent results either by direct or reflex application. 75 PARAFFIN THERAPY METHODS OF APPLICATION Dipping method: After washing and drying the extremity, dip the part in and out of the bath quickly, allow time between dipping for congealing, dip again, and keep repeating until the thickness of the paraffin is from 1/4 inch to 1/2 inch. Keep the fingers spread apart when dipping the hands. 76 77 PARAFFIN THERAPY METHODS OF APPLICATION Depending upon the intended duration of the treatment , wrap the part in wax paper (saran wrap, plastic bag) and insulate all around with a towel. When the treatment is completed, remove the paraffin and discard it. 78 PARAFFIN THERAPY METHODS OF APPLICATION The part treated should now be massaged and passively exercised. The entire treatment usually takes about 20 to 30 minutes. The advantage of this method is that the body part can then be elevated, reducing the potential for swelling. 80 PARAFFIN THERAPY METHODS OF APPLICATION Immersion method: For heat treatments of shorter duration, 10 to 30 minutes, use the immersion method. Dip the part in and out of the bath quickly so that a thin coating of paraffin congeals on the skin. 81 PARAFFIN THERAPY METHODS OF APPLICATION Repeat several times until the glove of paraffin is of sufficient thickness to allow the part to remain in the bath with comfort. Keep the part immersed from 10 to 30 minutes. At the end of the treatment, remove the wax and discard it. 82 PARAFFIN THERAPY METHODS OF APPLICATION The advantage of the immersion technique is that the source of heat is constant, so the therapeutic temperature can be maintained for a longer period. PARAFFIN THERAPY METHODS OF APPLICATION Brush on method: To apply paraffin bath heat treatment to parts of the body which cannot be immersed in the paraffin bath conveniently, paint the surface rapidly with a soft paint brush. When first applied, the paraffin will feel very warm, keep brushing until a thick coating covers the area. 84 PARAFFIN THERAPY BRUSH ON METHOD Allow it to remain for twenty to thirty minutes. After removal, discard the wax. The part treated should now be massaged and passively exercised. 85 86 WHIRLPOOL DR. GRANT 87 WHIRLPOOL WARM Whirlpools are often used in situations when heat needs to be combined with exercise. The whirlpool must be large enough to hold the body part to be treated and the following guidelines should be followed. 88 WHIRLPOOL GUIDELINES Temperatures should be 98 degrees F to 110 F for treatment of the arm and hand , 98 degrees F to 104 F for treatment of the leg and foot , and 98 degrees F to 102 degrees F for full body treatment. Treatment time should be between 15 and 20 minutes. Patients should be placed in a comfortable position in the whirlpool. 89 WHIRLPOOL CONTRAST THERAPY Contrast Therapy A contrast bath involves the alternating immersion of the involved body part in warm water and cold water. Usually, the wrist and hand or foot and ankle are treated, though the entire upper and lower member could be treated using two whirlpool tanks. Contrast Therapy The duration of immersion in each temperature water is variable, as is the number of times immersed during a single treatment session. A suggested sequence is to start with 3 minutes in warm , followed by 1 minute in cold, with the sequence repeated five times. WHIRLPOOL GUIDELINES The jet stream of the whirlpool should not be directed to the affected part, rather the stream should be directed towards the opposite side of the tank of the affected part. The water in the whirlpool should be changed regularly to avoid bacterial contamination. 93 INDICATIONS The principle indication for a warm whirlpool is to provide therapeutic warming of a larger area of the body than can be achieved readily with a hot pack. The effective depth of therapeutic heating is the same at approximatly 1 cm. Contraindications Lack of normal temperature sensibility Peripheral vascular disease with compromised circulation. Over tumors Coronary artery disease ICED WHIRLPOOL SHORT-WAVE DIATHERMY DR. GRANT Pain Alliance97 Institute SHORT-WAVE DIATHERMY Uses high frequency currents to heat the body tissues The heat results from the resistance offered by the tissue to passage of the electric current. 98 SHORT-WAVE DIATHERMY The patient’s sensation is an important guide as to the regulation of dosage, as it should produce only a mild comfortable sensation of warmth and not a sensation of heat It is imperative that the sensory perception of the patient be normal in the use of diathermy. 99 PRECAUTIONS Remove metallic pins, buttons, hair pins Metallic objects must not contact the patient as they will concentrate the heat and could cause burns. pins, keys jewelry, watches and buckles. 100 DOSAGE LEVEL 1 For patients who have no appreciable specific pain or in the treatment of visceral conditions, gradually increase temperature to where the patient just perceives a comfortable yet distinct sensation of “velvety” warmth. 101 Dosage Level II For patients who have pain, the temperature is increased to a point just below the level of Dosage I. No detectable sensation of warmth should be perceived by the patient. 102 GENERAL RULE The more acute the condition to be treated, the less temperature elevation and the shorter the treatment duration. 103 GENERAL RULE The thicker the body part to be treated, the greater should be the electrode -skin distance, which is provided by air spacing or towels. 104 AIR SPACE 106 107 108 109 TREATMENT OF LOW BACK PAD ELECTRODES DRUM ELECTRODE 113 114 INDICATIONS URI Chronic osteoarthritis Prostatitis 115 CONTRAINDICATIONS Over pregnant uterus Over wet skin Patients with pacemaker Peptic ulcers Rheumatoid arthritis Malignancy 116 MICROWAVE DIATHERMY DR. GRANT Pain Alliance Institute MICROWAVE DIATHERMY Microwave diathermy is the easiest to apply of the forms of deep heating. The area which can be treated at any given time is limited to a comparatively small field. Depth is limited to subcutaneous tissues and the more superficial musculature. MICROWAVE DIATHERMY Microwave diathermy is ineffective in treatment of the deeper and larger joints. Involves the production of electromagnetic energy at a frequency of 2,450 MHz. On application, check skin sensation, thoroughly dry skin prior to application MICROWAVE DIATHERMY Remove any metal in or near the field. Do not treat over dressings, bandages, etc.. Do not use toweling between the director and the skin. Do not treat over or near the eyes. Use great care over bony prominences. MICROWAVE DIATHERMY Microwave diathermy units require a period of time to warm up. Microwave diathermy is best used to treat conditions that exist in those areas of the body that are covered with low subcutaneous fat content. INDICATIONS Whenever mild heat build up or associated reflexes are desired in a specific site that is localized and not too deep, microwave is the treatment of choice. CONTRAINDICATIONS General contraindications to heat should be observed. Never over edematous tissues Over adhesive tape Near metallic implantsB PHYSIOLOGIC EFFECTS The configuration of a pattern is determined and controlled by the distance that it is placed from the patient and the shape of the reflector. The power output of the microwave unit is adjusted in accordance with the size and shape of the body part treated. PHYSIOLOGIC EFFECTS The smaller heat output of a microwave unit warms tissues in a much more local area. There is little penetration into deeper organs. Most of the effects of microwave radiation are due to heating of tissues by conversion. PHYSIOLOGIC EFFECTS The heat build up occurs mainly because of the resistance offered by tissue constituents to high frequency current, and a specific temperature distribution results within body tissues. MICROWAVE DIATHERMY SUMMATION Contact is not necessary, and smaller confined areas can often be treated more effectively. The field that can be heated at any one time is relatively small. Microwave has little, if any effect on deep joints or viscera MICROWAVE DIATHERMY PRECAUTIONS If vigorous heating effects are desired, the applicator must be brought close to the surface of the skin. The applicator should not be brought into contact with the skin. MICROWAVE DIATHERMY PRECAUTIONS Avoid sweat droplets forming on the skin that can be selectively heated. During treatment near the head, the eyes should be shielded with special goggles. Watches must be kept away from the high frequency field, MICROWAVE DIATHERMY PRECAUTIONS Hearing aids must be placed at least 4 feet from the treatment field. The director should be placed from 1-7 inches from the patient, depending on the type that is used. TREATMENT DURATION A treatment duration exceeding 20 minutes is inadvisable 133 134 135 RECTANGULAR APPLICATOR CRYOTHERAPY COLD PACKS, ICE MASSAGE 137 CRYOTHERAPY DEFINITION: The therapeutic use of cold. Ice is inexpensive, readily available to both practitioner and patient and can be used in a variety of forms. 138 CRYOTHERAPY Has relatively few contraindications, and can be very effective in the treatment of pain, edema, spasm and inflammation, especially in the first 24 to 48 hrs after an injury. 139 CRYOTHERAPY In many instances in which heat is considered the modality of choice for its “soothing” qualities, cooling would probably afford longer lasting and more complete results, and therefore should be considered more often. 140 CRYOTHERAPY EFFECTS Anesthesia Analgesia Reduction of edema Reduced Muscle spasm Reduced Spasticity Reduced manual Dexterity 141 CRYOTHERAPY INDICATIONS Acute sprains and strains Acute inflammatory processes Acute trauma Acute and Chronic muscle spasm Spasticity associated with neurological disorders 142 CRYOTHERAPY CONTRAINDICATIONS Caution with geriatrics , infants, cachexics Individuals with psychological aversion to cold Hypersensitive individuals 143 CRYOTHERAPY APPLICATIONS Ice packs Ice massage Cold compresses Extremity baths Vapocoolant sprays 144 145 146 ICE MASSAGE ICE PACK 149 150 COLD HYDROCOLLATOR COLD SPRAY Cold sprays such as Fluro-Methane or ethyl cholrde, do not provide adequate deep penetration, but they do provide adjunctive therapy for acupressure techniques to reduce muscle spasm. Cold spray is an extremely effective technique in the treatment of myofascial trigger points. COLD SPRAY PRECAUTIONS Include protecting the patient’s face from the fumes and spraying the skin at an acute rather than a perpendicular angle. Cold spray is indicated when stretching of an injured part is desired along with cold treatment. COLD SPRAY TREATMENT The area shold be sprayed and then stretched. Spasm should be reduced. Treatment should be distal to proximal. A quick jetstream spray or stroking motion should be used Cooling should be superficial; no frosting should occur. COLD SPRAY TREATMENT Cold sprays should be used in conjunction with acupressure. Treatment time should be set according to body segment. Hold cold spray 12 to 18 inches away from the treatment surface. Apply the spray in one direction only SPRAY AND STRETCH THERAPEUTIC ULTRASOUND DR. GRANT Pain Alliance157 Institute THERAPEUTIC ULTRASOUND Therapeutic ultrasound is that which is used for therapeutic (rather than diagnostic) purposes and is usually produced at 1 megacycle or 1 million cycles per second 158 THERAPEUTIC ULTRASOUND US has replaced diathermy for many types of conditions because it is less time consuming and penetrates tissues well. 159 ULTRASOUND There is less danger of burning Recommended treatment time is between 5 and 10 minutes It is capable of penetrating 4 - 6 cm into the tissues. 160 ULTRASOUND Ultrasound by its very nature , has the ability to irritate the patients skin. While the benefits of ultrasound far outweigh any disadvantages, certain precautions should be observed to assure maximum safety and comfort for your patients. 161 ULTRASOUND Continuous US causes a thermal effect. The friction caused by the vibration within the patient’s tissues will produce heat. Because US is transmitted by skin and fat, the heat can be directed to the deeper muscle layers where it is needed. 162 PULSED ULTRASOUND The energy is on for a short period of time, then off, alternating so that the “on time” or duty cycle is approximately 5-50% of the total time. The “off time” allows the tissues to disperse the heat created, thereby minimizing or eliminating the thermal effect. 163 PULSED ULTRASOUND With the 5% duty cycle, there is virtually no heating With the 50% duty cycle, some heating occurs. Pulsating US is advantageous when the thermal effect may be detrimental. 164 ULTRASOUND EFFECTS Tissue temperature rise Decreased nerve conduction velocity Increased circulation Increased tendon extensibility Reduced adhesion formation Decreased Muscle pain relaxation 165 ULTRASOUND INDICATIONS Neuromuscular, musculoskeletal disorders Sprains and strains; adhesive capsulitis Arthritic conditions - acute and chronic Bursitis, tendinitis, including calcific tendinitis 166 ULTRASOUND INDICATIONS Plantar warts Hematomas Adhesions Neuromas, scars, dupuytrens contracture 167 PRECAUTIONS The rate of speed at which the applicator moves across the skin is very important in determining how much US is delivered. If the rate is too slow, the patient may feel periosteal pain. 168 PRECAUTIONS If the rate is too fast, or if the applicator head becomes uncoupled with the skin, the amount of treatment is reduced and the sound head can overheat. Some patients’ skin is more sensitive to US output. This can cause a reaction similar to heat rash. 169 170 PRECAUTIONS It is possible for a patient to suffer a burn from US therapy if the therapy is not administered properly. Burns can occur for the following reasons. 171 PRECAUTIONS Over heating of the cutaneous tissues may occur if: The intensity is set too high Transducer is moved too slowly Transducer surface is not kept parallel to the skin surface Treating an area where sensory nerve damage is present with a loss of normal sensation. 172 PRECAUTIONS Over heating of the periosteum may occur if: The transducer is held too close to the bone The intensity is set too high The transducer is moved too slowly 173 PRECAUTIONS Burns can be avoided as long as the treatment causes no pain, tingling, excess heat or aching (for patients with normal skin sensation). Use sufficient coupling agent and make sure there are no bubbles in the gel. When treating in water, clear the bubbles off the sound head and off the patient’s skin. 174 PRECAUTIONS An uncalibrated or faulty ultrasound unit can cause shear waves and standing waves that can also cause burns. 175 PENETRATION OF ULTRASOUND WAVES The correct frequency should be selected for the depth of penetration desired: 1 MHz provides deeper penetration 2 MHz provides moderate penetration 3 MHz provides more shallow penetration. 176 DUAL SOUNDHEADS COUPLING The term coupling refers to the ability to deliver US waves from the sound head to the skin surface with as little impedance or dissipation of power as possible. 178 COUPLING The best coupling is achieved when the US head has full, direct contact over the treatment site or when the treatment site and sound head are separated only by a substance that provides excellent conductance. Water is an excellent conductor of US waves. 179 COUPLING Air is a poor conductor of US waves. If any part of the sound head is exposed to air during the treatment, coupling is decreased. When treating a patient outside of water, the sound head must maintain good contact with the patient’s skin at all times. 180 COUPLING In addition, a good conductive gel or lotion should be used to ensure the best possible coupling. Since air is a poor conductor of ultrasound, it is not advisable to introduce air into the water during an ultrasound immersion treatment. 181 COUPLING The air bubbles in a whirlpool, for example, can decrease the effective ultrasound therapy to the patient. 182 183 184 CONTRAINDICATIONS (should not be applied to:) Epiphysis of growing bones Over reproductive organs Over a gravid uterus Over the heart Over the eye; over anesthetic areas Over ischemic areas; directly over the spinal column or brain. 185 CONTRAINDICATIONS (should not be applied to:) Over a laminectomy site Over viscera (stomach, spleen, liver) Over total joint replacements (the effect of US on the new plastics is unknown) 186 CONTRAINDICATIONS Over a fracture (until well healed) Deep vein thrombosis Arterial disease, hemophilia, malignancy TB of the lungs or bone Over the thoracic region of a patient with a pace maker 187 CONTRAINDICATIONS Implants of any electrical nature Multiple Sclerosis Osteomyelitis Skin diseases Tissue or bone with acute sepsis 188 PRECAUTIONS Ultrasound must be used cautiously when there is a tendency to hemorrhage following a acute trauma or fracture. Caution when using on acute bursitis. DO NOT use in continuous duty cycle. 189 Techniques of Application Specific practical recommendations as to how ultrasound may best be applied to a patient therapeutically are quite controversial and are based primarily on the experience of the clinicians and therapists who have used it. APPLICATION OF ULTRASOUND Apply coupling medium to the part being treated and place the transducer against the coupling medium. The unit should never be turned on without coupling medium because the crystal may over heat. 191 APPLICATION OF ULTRASOUND Keep the transducer moving slowly Turn the intensity up to the desired level (patients comfort and not to exceed 1.5 watts/sq.cm) Avoid bony prominences and keep the transducer parallel to the skin as much as possible 192 193 APPLICATION OF ULTRASOUND The patient may get a mild sense of warmth. If the patient gets too hot, or uncomfortable, the wattage should be reduced to a tolerable level Treat for the desired time (8-10 minutes maximum for topical application). See notes on duration of treatment. 194 US IMMERSION METHOD Good for treating hands, wrists, feet and elbows Place the transducer and the treating part in a container of water 195 US IMMERSION METHOD Keep the transducer moving slowly and within 1cm (1/2 - 1 inch) of the part being treated. Duration: acute 3-4 minutes; chronic 5-10 minutes 196 197 198 199 200 Frequency of Treatment It is generally accepted that acute conditions require more frequent treatments over a shorter period of time, whereas more chronic conditions require fewer treatments over a longer period of time. Frequency of Treatment Acute conditions may be treated using low intensity or pulsed ultrasound once or even twice daily for 6 or 8 days until acute symptoms such as pain and swelling subside. In chronic conditions, when acute symptoms have subsided, treatment may be done on alternating days. Ultrasound treatment should continue as long as there is improvement. Frequency of Treatment It has been recommended that ultrasound be limited to 14 treatments in the majority of conditions, although this has not been documented scientifically. More than 14 treatments can reduce both red and white blood cell counts. After 14 treatments of ultrasound some authors avoid using it for 2 weeks. Duration of Treatment Generally the suggested duration has been too short. Typically recommended treatment times have ranged between 5 and 10 minutes in length; however those times may be insufficient. The length of time is dependent on several factors: 1 . Size of the area to be treated Duration of Treatment 2 . The intensity in W/sq.cm 3 . The frequency 4 . The desired temperature increase. Specific temperature increases are required to achieve beneficial effects in tissue. The therapist must determine what the desired effects of the treatment are before a treatment duration is set. Duration of Treatment An accepted recommendation is that the ultrasound be administered in an area two times the size of the soundhead. If thermal effects are desired in an area larger than this, obviously the treatment time needs to be increased. The higher the intensity applied in W/sq.cm, the shorter the treatment time Tissue Heating Tissue heated by ultrasound loses its heat at a fairly rapid rate; therefore, stretchng, friction massage, or joint mobilization should be performed immediately postultrasound. To increase the duration of the stretching window, it is recommended that stretching be done during and immediately after US application. ELECTRICAL STIMULATION DEVICES DR. GRANT CLASSIFICATION Electrical stimulation devices can be classified in several ways. One method is based on the type of current that is used (AC or DC) Secondly, the amount of voltage that may be produced (Low voltage or High voltage) Thirdly, by reference to some unique aspect of the current that is used (IF, Russian Stim.) INTRODUCTION TO ELECTROTHERAPY Electrotherapy - in particular interferential therapy - has proven to be one of the more successful therapies. Such popularity is for good reason. Practitioners using electrotherapy devices have experienced favorable results in relieving pain. 211 INTRODUCTION TO ELECTROTHERAPY The degree of success achieved in adding electrotherapy to a practice is measured in terms of how quickly and efficiently it can be learned and implemented. Electrotherapy devices are now “user friendly” 212 INTRODUCTION TO ELECTROTHERAPY Interferential quadrapolar, premodulated quadrapolar premodulated (bipolar), and Russian and biphasic stimulation , conveniently and economically can be housed in one easy-to -use unit. 213 INTERFERENTIAL THERAPY The name Interferential therapy stems from the concept of two currents interfering with each other This becomes readily apparent when one views the four electrodes that are necessary to produce the standard interferential effect in a patient 214 INTERFERENTIAL THERAPY I.F. is one of a number of electrical stimulation techniques used in modern physiotherapy. The common feature of all modalities is the ability to facilitate healing in damaged tissues However, I.F. has a number of advantages 215 INTERFERENTIAL THERAPY The beat frequency in Hz is simply the difference in frequency between the two medium frequency currents. This “beating” is the actual “interferential effect” The beat frequency relates solely to the number of times per second the intensity increases and decreases. 216 INTERFERENTIAL THERAPY PRE-MODULATED BIPOLAR It is possible to deliver I.F. currents to a patient using two, instead of the conventional four electrodes. In this system, the two currents are “mixed” in the machine and delivered to the patient via two electrodes (premodulated). 217 INTERFERENTIAL THERAPY PRE-MODULATED BIPOLAR Premodulated bipolar therapy helps to reduce pain and increase range of motion. In some cases, it provides an effective substitute for quadrapolar treatment especially when treating small areas of the body where four electrodes cannot be placed. 218 INTERFERENTIAL THERAPY PRE-MODULATED BIPOLAR Premodulated bipolar therapy utilizes one output jack, and produces a composite wave form identical to the interferential current, while using only two electrodes. 219 INTERFERENTIAL THERAPY The average treatment time for most applications being 20 to 30 minutes. On the first treatment session, it is wiser to halve this, in order to ensure that there is no abnormal response from the patient. 220 INTERFERENTIAL THERAPY TREATMENT DURATION There has never been a set number of treatment sessions for any particular clinical problem since all patients and problems are different. 221 INTERFERENTIAL THERAPY TREATMENT DURATION However, if the overall treatment program has been carefully designed and delivered , then good results should be expected fairly quickly. 222 INTERFERENTIAL THERAPY TREATMENT DURATION I.F. like other forms of electrotherapy, are meant to be used as an adjunct to other forms of treatment. In most cases, six to ten sessions of I.F., together with other measures should produce considerable improvement in the patient. 223 INTERFERENTIAL THERAPY There is no point in continuing with a technique which appears to be having no effect. If the patient’s condition is unchanged after one or two treatments, then the situation needs re-assessing. 224 INTERFERENTIAL THERAPY Assuming that the machine is working correctly and is applied properly, then poor results should indicate possible change in electrode position and/or a change in frequency/intensity. The physiological effect of I.F. depends on the frequency of the current. 225 INTERFERENTIAL THERAPY PHYSIOLOGICAL OBJECTIVES Pain relief both acute and chronic Reduction of edema re-education and strengthening of muscle. Stimulation and improvement of circulation General facilitation of healing 226 INTERFERENTIAL THERAPY I.F. can and should be combined with other modalities except ice and Diathermy. Combining treatments implies giving two different but complimentary treatments at different times or in some instances at the same time (moist heat) 227 INTERFERENTIAL THERAPY The generally accepted range of frequency is 0 to 150 Hz, with a low range from 0 to 10 Hz, commonly accepted as the appropriate treatment for increasing local blood circulation; and a high range from 80 to 150 Hz which is used for pain relief. 228 INTERFERENTIAL THERAPY CONTRAINDICATIONS Pacemakers Thrombosis Cardiac Conditions Bacterial Infections Malignancy 229 INTERFERENTIAL THERAPY WARNINGS Pregnancy Implants of any electrical nature Transcerebrally Skin diseases 230 231 235 236 237 239 RUSSIAN STIMULATION DR. GRANT Pain Alliance Institute RUSSIAN STIMULATION Dr. Y.M. Kots, a Russian physiatrist, has been credited with the development of Russian Stim during the late 1960’s. Presented seminars in the U.S. on the use of EMS to augment strength gain RUSSIAN STIMULATION The stimulators developed in the U.S. after Dr. Kots presentations were termed Russian current generators. These stimulators deliver a medium frequency (2,000 to 10,000 Hz) The peak current intensity stimulates muscle very well and is comfortable. RUSSIAN STIMULATION The initial uses of Russian Stimulation in the U.S. were for rehabilitation following surgical procedures such as ACL repair. Strengthening of the quadriceps muscle to correct atrophy of disuse has become a standard, effective treatment procedure. RUSSIAN STIMULATION AC medium frequency 2500 Hz Primary purpose is for muscle rehab/re-education. RUSSIAN STIMULATION PHYSIOLOGICAL EFFECTS Muscle strengthening and reeducation Decrease edema Increase blood flow Reduces muscle spasm RUSSIAN STIMULATION INDICATIONS Chronic back pain Post-injury muscle atrophy and/or wasting Post-casting Muscle spasms RUSSIAN STIMULATION CONTRAINDICATIONS Pacemakers Malignant lesions Upper thorax (anterior) Pregnancy RUSSIAN STIMULATION APPLICATION 10/50 pre-set Start with low on times and long off times with long ramp times As strength begins to return, increase on times and decrease off times with shorter ramp RUSSIAN STIMULATION PAD PLACEMENT Bipolar technique Origins and insertions RUSSIAN STIMULATION SUMMARY When an electrical stimulation is applied to muscle or nerve tissue, the result will be tissue membrane depolarization, provided that the current has the appropriate intensity, duration, and waveform to reach the tissue’s excitability threshold. RUSSIAN STIMULATION SUMMARY Muscle contraction will change according to changes in current. As the frequency of the electrical stimulus increases, the muscle will develop more tension as a result of the summation of the contraction of the muscle fiber through progressive mechanical shortening. RUSSIAN STIMULATION SUMMARY Increases in intensity spreads the current over a larger area and increases the number of motor units activated by the current. Increases in the duration of the current also will cause more motor units to be activated. RUSSIAN STIMULATION SUMMARY Electrically stimulated muscle contractions are used clinically to: 1 . Help with muscle re-education 2 . Muscle contraction for muscle pumping action 3 . Reduction of swelling 4 . Prevention or retardation of atrophy RUSSIAN STIMULATION SUMMARY 5 . Muscle strengthening 6 . Increasing range of motion in tight joints. RUSSIAN STIMULATION SUMMARY It does appear that the intensity of contraction is positively correlated to strength gains. The stronger the contraction, the greater the gain. RUSSIAN STIMULATION 10/10 PRE-SET Physiological effects are as follows: 1.Decrease edema via pumping effect 2.Break spasms by fatigue of muscles 3.Increase blood flow 10/10 PRE-SET INDICATIONS Muscle spasms Edematous situations 10/10 PRE-SET PAD PLACEMENT Bipolar technique Origins and insertions Polarity not important BIPHASIC STIMULATION DR. GRANT BIPHASIC THERAPY In Biphasic stimulation mode the ouput of the modality allows you to choose a muscle contraction/relaxation cycle that is most suited for the individual patient and for the desired treatment. When the cycle is chosen, each musclestimulating burst is followed by a relaxation (rest) cycle. BIPHASIC THERAPY There are 3 modes of treatment in Biphasic stimulation: 1 . Normal 2 . Reciprocal 3 . Co-Contraction You will need to decide which mode is to be used and attach the appropriate number of leads needed before setting up the treatment. BIPHASIC THERAPY Normal: Use one channel with one lead wire (two electrodes) The contraction/relaxation cycle is selected from an option list of 10/10, 10/30, 10/50 and continuous (there is no rest cycle with continuous). The continuous cycle is not recommended for EMS. BIPHASIC THERAPY Co-Contraction: Use two channels and two lead wires (four electrodes). Each pair of electrodes is placed over a different muscle group. This treatment fires the two muscle groups simultaneously - Contraction and rest cycles for both treatment areas occur at the same time. Two channels are required (1 and 2) BIPHASIC THERAPY Reciprocal: Use two channels and two lead wires (four electrodes) for this treatment. The reciprocal muscle stimulation fires two muscle groups (such as flexors/extensors) one after the other. Example: 10/30 setting, the modality would deliver stimulation for 10 seconds to the first muscle followed by 10 seconds of stimulation to the reciprocal muscle. BIPHASIC THERAPY Press the Biphasic key Choose the treatment mode Choose the contraction/rest times Choose the ramp setting Raise the intensity to the desired level For co-contraction or reciprocal treatments, choose the second channel and set the intensity for this channel Press start BIPHASIC THERAPY When choosing the Biphasic function, the default settings are automatically selected: 1 . Normal treatment mode 2 . 10/30 contraction/rest times 3 . Ramp up and down time : .5 sec. Increase the intensity to the patients tolerance Press start BIPHASIC THERAPY CAUTION NEVER TURN THE POWER ON OR OFF WHILE THE UNIT IS CONNECTED TO THE PATIENT HIGH VOLT THERAPY 275 Pain Alliance Institute HIGH VOLTAGE THERAPY Manufactures of HVT equipment offer guidelines for the choice of polarity in particular situations, but research has not yet substantiated these guidelines. Polarity appears relatively unimportant in many circumstances. 276 HIGH VOLTAGE THERAPY In contrast to low voltage, high voltage offers a more comfortable current that is safer to use and more universal in its application. Because of its high peak current and short pulse duration, penetration is deeper, with less sensory disturbance and less heat production. 277 HIGH VOLTAGE THERAPY EFFECTS Analgesia Edema absorption Muscle contraction Increased peripheral circulation 278 HIGH VOLTAGE THERAPY INDICATIONS Soft tissue injuries Sciatica Arthritic conditions Nonsystemic edema Muscle spasm, muscle reeducation Trigger Point therapy 279 HIGH VOLTAGE THERAPY CONTRAINDICATIONS Malignancy Patients with pacemakers Pregnancy Over open wounds Transcerebrally Cardiac conditions 280 HIGH VOLTAGE THERAPY If treating trigger points, acupuncture points, or motor points, use a probe instead of active pads. Turn the intensity to the level of mild sensory stimulation and probe the area to locate the exact location to be stimulated. 281 HIGH VOLTAGE THERAPY Continue to increase the intensity until the desired effect is achieved. Trigger points will usually become less painful in 15 - 30 seconds. 282 HIGH VOLTAGE THERAPY APPLICATION The treatment setup utilizes a double-output lead with two electrodes; an active and a dispersive electrode (monopolar technique). The size of the dispersive electrode is recommended to be double the area of the active electrode. HIGH VOLTAGE THERAPY APPLICATION If desired, the active output of the lead may be bifurcated to attach additional active electrodes; however, the combined total of the active electrodes must be less than the area of the single dispersive electrode. HIGH VOLTAGE THERAPY APPLICATION In the output labeled “HV” connect one lead with two output connections. It is best to use a lead that is marked to show the polarity of the output end. The active electrode is connected to the lead output that is marked positive The dispersive electrode is connected to the lead output that is marked negative. HIGH VOLTAGE THERAPY APPLICATION During treatment current flows in one direction between the electrodes. Polarity of the treatment is not controlled by the polarity of the lead wires, but is controlled by the polarity selection you make on the front panel of the unit. HIGH VOLTAGE THERAPY APPLICATION Changing the polarity in the treatment parameters has the effect of reversing the direction of the current flow between electrodes. It is important to attach the active electrode to the positive output of the lead wire to ensure the polarity you have selected is delivered. HIGH VOLT APPLICATION . . Press HV and choose polarity The available options include positive (+) , negative (-), or both. When both are selected, the unit alternates between the two, delivering each polarity for approximately 30 seconds. Choose the contraction/rest cycle times. . HIGH . . . . VOLT APPLICATION Choose the Ramp setting Choose High or Low pulse rate range. High is for acute and Low is for chronic Raise the intensity to the patients tolerance. Press Start . LOW VOLTAGE STIMULATORS Dr. Grant LOW VOLTAGE THERAPY Low frequency alternating currents are utilized because of the continued need for electrical stimulation of atrophied muscle, especially for patients with CNS lesions. 293 LOW VOLTAGE THERAPY When low volt AC current of sufficient intensity is applied to the muscle, a contraction will be noted as long as the current is allowed to flow. The muscle will contract in time with the frequency(or pulses per second). At one pulse per second, the muscle will contract and relax once per second. LOW VOLTAGE THERAPY As the frequency is increased, the muscle pumps faster until you reach a stage (approximately 35 pps) where the muscle is incapable of relaxing before the next electrical pulse arrives ( a “tetanized” contraction). A steady contraction is noted . As you progress beyond 35 pps, the contraction becomes stronger. LOW VOLTAGE THERAPY EFFECTS Contraction of enervated muscle Pain relief Edema reduction 296 LOW VOLTAGE THERAPY INDICATIONS Stimulation of weak and/or atrophied muscles Nonsystemic edema 297 LOW VOLTAGE THERAPY CONTRAINDICATIONS Through the brain, heart or eyes Over bony prominences Fractures Skin lesions Malignancy Anesthetic areas Over a gravid uterus 298 IONTOPHORESIS Dr. Grant IONTOPHORESIS Iontophoresis is a therapeutic technique that involves the introduction of ions into the body tissues by means of a direct electrical current. The manner in which ions move in solution forms the basis for iontophoresis. IONTOPHORESIS Positively charged ions are driven into the tissues from the positive pole, and negatively charged ions are introduced by the negative pole. The force that acts to move ions through the tissues is determined by both the strength of the electrical field and the electrical impedance of tissues to current flow. IONTOPHORESIS The quantity of ions transferred into the tissues through iontophoresis is determined by the intensity of the current or current density at the active electrode, the duration of the current flow, and the concentration of ions in solution. IONTOPHORESIS Continuous direct current must be used for iontophoresis, thus ensuring the unidirectional flow of ions that cannot be accomplished using a bi-directional or alternating current. Electrodes may be either borrowed from other ES or commercially manufactured ready-to-use disposable electrodes. IONTOPHORESIS Iontophoresis is used to treat Inflammatory musculoskeletal conditions, for analgesic effects, scar modification, wound healing, and in treating edema, and calcium deposits. Probably the single most common problem associated with iontophoresis is a chemical burn that usually occurs as a result of the DC itself and not because of the ion being used in treatment IONTOPHORESIS Conditions Treated Spasm: Calcium, magnesium Inflammation: Hydrocortisone, salicylate dexamethosone. Analgesia: Lidocaine, magnesium Edema: Magnesium, mecholyl, hyaluronidase, salicylate Ischemia: Magnesium, mecholyl, iodine Fungi: Copper TENS DR. GRANT 306 Pain Alliance Insitute PHORESOR TENS TENS should apply to any form of electrical stimulation that is applied via surface electrodes. The term has been used for small portable stimulators that can be attached to the belt or clothing and used for various time periods for the relief of pain. 308 TENS UNIT TENS In general the primary effect of TENS is the relief of pain. Many health practitioners are finding TENS to be an effective, safe, noninvasive, and cost effective method of treating acute, chronic and psychogenic pain of innumerable origins. 310 TENS INDICATIONS Chronic pain Acute pain Intractable pain (TENS can provide adequate relief of pain secondary to malignancy). Results are best with trunk and extremity pain and worst with pelvic and perineal pain. 311 TENS INDICATIONS Rehabilitation: The use of TENS for the reduction of pain during rehabilitation can increase performance and shorten disability. Care must be taken to not allow the TENS to obliterate pain to the extent that the patient loses protective cues and overstresses the part being rehabilitated. 312 TENS CONTRAINDICATIONS Pacemakers Carotid nerve stimulation Laryngeal stimulation During pregnancy 313 TENS ELECTRODE PLACEMENT Electrode placement is one of the most critical factors for the success of TENS Directly over or around the painful site Over trigger points 314 TENS ELECTRODE PLACEMENT Over acupuncture points Within a specific dermatome At the site of the corresponding nerve root. TENS The most significant complication of TENS is local skin rashes produced by the conduction gel or tape. Electrodes should be removed every day or two to clean the skin and inspect the area. 316 ELECTRODES Initially, dry pads were provided that required the use of gel. This was messy, provided uneven conductivity, and caused minor skin burns at high currents. At present, self-adhesive electrodes are available that are semi-disposable and generally affordable. ELECTRODES Most TENS devices recommend carbon based electrodes. In this day and age of concern over deadly infectious diseases, it has become common practice for practitioners who use TENS clinically to keep a separate set of electrodes for the exclusive use of each patient. TENS There is no contraindications to 24 hour use of “high TENS”. “Low” TENS”, however, should be used only 30 - 40 minutes at a time, as “Low TENS” causes muscle contraction and may cause soreness if used for longer periods. 319 HiTENS The term TENS is often associated with the application of a high frequency, low-intensity current that is directed at closing the pain gate. This is sometimes referred to as conventional TENS, classic TENS, or HiTENS. HiTENS This particular form of TENS typically uses a spike or asymmetric rectangular wave with a pulse width of less than 200 microseconds. The frequency range varies between 50 to 150 Hz and the intensity is set at a mild sensory level (gentle tingling). HiTENS The stimulation is towards the large superficial sensory fibers (A-beta) This type of stimulation usually provides a fairly rapid and comfortable form of pain relief. HiTENS With this type of application, the onset of pain suppression usually occurs within minutes and lasts for approximately I hour after stimulation. HiTENS Stimulation times vary considerably from patient to patient. They may be as short as 15 minutes in some with no return of pain. others, such as immediate postsurgical patients, may find it helpful to leave the TENS on for hours at a time. HiTENS The electrode type, quality, and contact affect the level of comfort and the effectiveness of the procedure. Electrode placement is important to effect a positive response. HiTENS This high frequency form of TENS appears to work best when electrodes surround the injured area or are applied within the same spinal segments as the pain HiTENS The electrode position and intensity should be adjusted so that tingling can be felt throughout the area of pain. Electrode placement may need to be altered several times to supply adequate pain relief. LoTENS This form of TENS is intended to produce analgesia by stimulating the release of endorphins and enkaphalins. It is also referred to as “acupuncture-like TENS” or “noninvasive electroacupuncture.” It uses a high-intensity current and a very low frequency (1-5 Hz) LoTENS It appears that the higher the intensity of the stimulation, the greater the physiologic response. Unlike other forms of ES, LoTENS applications appear to be frequency- dependent with little room for variation. LoTENS The mechanism of action is via the release of endorphins and enkaphalins and because of the half-life of endorphins, the relief gained is typically longer lasting than that found with conventional TENS. LoTENS The time required to induce any significant endorphin release is between 20 and 45 minutes. LoTENS application may provide relief in some patients who are resistant to conventional TENS. BURST TENS Burst TENS consist of clusters of high-frequency pulses or trains (70100 Hz) that are repeated at an acupuncture frequency of 1 to 5 Hz. The pulse width and amperage are variable The intensity is raised to a motor level stimulus BURST TENS The strength of the contraction varies from barely perceptible to strong rhythmic pulses. As with LoTENS, the evidence indicates that a stronger stimulation produces better analgesia. BURST TENS The mechanism of pain relief is thought to be mixed with some stimulation of superficial sensory fibers and some endorphin response. The major advantage of this modification over LoTENS is the level of comfort afforded. EFFECTIVENESS OF TENS The application of tens, particularly in the chronic pain patient can be enhanced or hindered by a variety of factors. the following factors may interfere with the successful application of TENS. FACTORS INTERFERING WITH SUCCESS OF TENS Medication - particularly corticosteroids, narcotics, and diazepam, can deplete the body of the chemicals necessary to control pain. FACTORS INTERFERING WITH SUCCESS OF TENS Prolonged Pain and Stress Patients who have been in pain for extended periods of time may fail to respond to TENS for many reasons including depression. FACTORS INTERFERING WITH SUCCESS OF TENS Senility - interferes with patient understanding and the manual dexterity necessary both to connect electrodes and to control the TENS devices. FACTORS INTERFERING WITH SUCCESS OF TENS Patient Understanding - As with other forms of treatment, compliance lessens if patients do not understand the purpose of the therapy, patients who are treated with TENS, especially those who use TENS units on an outpatient basis, should be informed- FACTORS INTERFERING WITH SUCCESS OF TENS - regarding the purpose of treatment, the application techniques, electrode placement, and equipment use. Lack of co-operation - Patients who are unwilling to learn how to use the TENS unit properly or who are noncompliant probably will not respond well. FACTORS INTERFERING WITH SUCCESS OF TENS Poor Posture or Body Mechanics Many patients have pain due to sustained postural stresses and/or biomechanical dysfunction. FACTORS INTERFERING WITH SUCCESS OF TENS It is helpful to provide pain relief for these patients, it is also important to address such problems with appropriate ergonomic modifications and/or mechanical therapies to eliminate or minimize any continued aggravation. FACTORS THAT ENHANCE THE APPLICATION OF TENS Wean from Medications Appropriate communication with medical providers is necessary to determine the most effective painrelieving approach. FACTORS THAT ENHANCE THE APPLICATION OF TENS Tryptophan A naturally occurring sedative, a precursor of serotonin, aids in reducing pain and stress levels. It is found in high quantities in eggs, meat, poultry, and dairy products. FACTORS THAT ENHANCE THE APPLICATION OF TENS Stress Reduction - Reducing and eliminating stress helps improve the efficacy of TENS. One of the most useful stress reduction techniques is relaxation therapy FACTORS THAT ENHANCE THE APPLICATION OF TENS With practice, some patients may find that they can control their pain without the use of TENS or pharmaceuticals. FACTORS THAT ENHANCE THE APPLICATION OF TENS Current modulations - Patients rapidly accommodate or adapt to a steady stimulus. When TENS is used for a prolonged time it may be helpful to modify the application technique by using different forms of TENS or by varying the current parameters. FACTORS THAT ENHANCE THE APPLICATION OF TENS Variable Electrode Placements - As with varying the parameters of stimulation, it is often helpful to vary the electrode placement , which not only helps to reduce patient accommodation, it also reduces the likelihood of skin irritation. FACTORS THAT ENHANCE THE APPLICATION OF TENS Patient Willingness to Cooperate and Experiment - Patient motivation is always a major factor in determining response to treatment, whether it includes TENS, manipulation, or exercise. FACTORS THAT ENHANCE THE APPLICATION OF TENS Improvement in Posture and Body Mechanics - Improving the working and living conditions of the patient may prevent or reduce many of the problems that produce and/or aggravate painful conditions TENS LONG TERM EFFECT As with many other treatment modalities, the long-term effectiveness of TENS is to a large extent determined by the manner in which it is originally presented to the patient. TENS LONG TERM EFFECT The success rate after several months of use varies widely, with some patients receiving significant relief whereas others may hardly be affected TENS LONG TERM EFFECT The success of TENS on a long term basis is dependent upon the willingness of both the doctor and the patient to experiment with different electrode placements, frequencies, intensities, and forms. MICROCURRENT DR. GRANT 354 Pain Alliance Institute MICROCURRENT This type of electrical modality uses an electrical current of less than 1 mA. They are subthreshold in nature and patients do not experience either the tingling sensation or muscle contraction seen with other electrical stimulators. MICRO CURRENT THERAPY It is postulated that microamperage stimulation functions to repair the injured cell membrane which, in turn, leads to a reduction of pain. Perhaps the most troubling area in the use of microamperage stimulation devices is the lack of understanding and uniformity of stimulation parameters. 356 MICRO CURRENT THERAPY To date, selection of appropriate parameters (frequency, intensity, pulse width, duration of treatment, etc.) are largely based on empirical observations and clinical experience. It does appear that the following parameters represent reasonable suggestions based on the available data. 357 MICRO CURRENT THERAPY Direct current is preferred due to the fact that it has a polarizing effect. Polarity - this may be the most crucial factor. It is generally accepted that a positive current is most useful in the early phases of treatment and a negative current in later phases. 358 MICRO CURRENT THERAPY Pulse width - in order to make the stimulus sufficient to change the cell membrane potential, it appears that a relatively long pulse width is necessary. Pulse widths vary from 50 microseconds to as long as .5 seconds. 359 MICRO CURRENT THERAPY Frequency - Acupuncture point stimulation appears to be most effective at low pulse rates, between 1-5 Hz. Pulse rates with microcurrent stimulation devices range from .5 per second to several hundred per second. 360 MICRO CURRENT THERAPY It is suggested that lower pulse rates are used for chronic conditions and higher pulse rates for more acute problems. 361 MICRO CURRENT THERAPY POINT STIMULATION Although microcurrent probe technique requires the active participation of the doctor or therapist, many believe that pain relief and an increase in joint range of motion can be accomplished in far less time than needed for other electrotherapy modalities. 362 MICRO CURRENT THERAPY PROBES Typically, the initial stage of treatment uses a hand-held probe that is either a solid blunt probe or a probe with a moistened cotton swab inserted within the hollowed tip of the probe. 363 MICRO CURRENT THERAPY PROBES When using probes, first affix new felt electrodes and saturate them with saline solution. Then apply firm pressure, but less than that which would cause more pain. 365 MICRO CURRENT THERAPY PROBES Tap water does not work well in most places anymore because of recent advances in desalination during water processing. As saline is a prescription product in the U.S., you can use contact lens cleaner, a conveniently packaged and inexpensive overthe-counter form of saline. MICROCURRENT APPLICATION For extremely hypersensitive people, such as fibromyalgia patients, it is better to start with a minimal amount of current. Even low level Micro currents may be uncomfortable in some patients. Start with more sensitive electrodes in these patients ( carbon, silver electrodes, probes with tap water) MICROCURRENT APPLICATION The patient should be in a relaxed position to receive maximum beneficial effects. The most important variable is the position of the probes, or pads. Place the probes or electrodes in such a way that if a line was drawn between them, that line would transect the problem area. MICROCURRENT APPLICATION Keep in mind that the electrode positioning may be transient, working well one day, but ineffective another day. As the problem begins to resolve, the electrode locations may require constant adjustments MICROCURRENT APPLICATION Keep in mind that the electrode positioning may be transient, working well one day, but ineffective another day. As the problem begins to resolve, the electrode locations may require constant adjustments MICRO CURRENT THERAPY Many doctors are familiar with acupoints, motor points, and trigger points and are experienced in their electrostimulation. Once these points are isolated, the current is set to a subsensory level and the points are stimulated (15 seconds). 371 MICRO CURRENT THERAPY NERVE ROOT TECHNIQUE In this method, both probes are used to stimulate adjacent interspinous spaces of involved vertebral segments for 12 - 20 seconds. Significantly enhanced pain control and improved segmental ROM have been reported when using this technique. 372 MICRO CURRENT THERAPY Enhancing restricted joint motion has been reported to be highly effective when combined with passive mobilization of the involved joint. Results are typically greater than when passive exercise is used alone to increase joint ROMs. 373 MICRO CURRENT THERAPY NERVE ROOT TECHNIQUE In this method, both probes are used to stimulate adjacent interspinous spaces of involved vertebral segments for 12 - 20 seconds. Significantly enhanced pain control and improved segmental ROM have been reported when using this technique. 374 MICRO CURRENT THERAPY Enhancing restricted joint motion has been reported to be highly effective when combined with passive mobilization of the involved joint. Results are typically greater than when passive exercise is used alone to increase joint ROMs. 375 MICRO CURRENT THERAPY PAD TREATMENT When pads are used, placement is proximal and distal to the site of involvement. 376 MICRO CURRENT THERAPY INDICATIONS Pain Tissue healing, including decubitus ulcers Several microamperage stimulators are being used for the treatment of acute and chronic sports injuries because of their analgesic, antiinflammatory, and healing properties 377 MICRO CURRENT THERAPY CONTRAINDICATIONS Demand - type cardiac pacemakers Over the carotid sinus Over the eyeball or eyelid Safety and effectiveness of microamperage stimulators has not been established in pregnancy; avoid the stimulation of any area that might affect the pregnancy. 378 VIBRATORY THERAPY DR. GRANT VIBRATORY THERAPY May be applied manually or mechanically, superficially with relatively horizontal oscillations, or to deeper tissues via percussion strokes. VIBRATORY THERAPY EFFECTS The primary action is kinetic Causes an increase in circulation and lymphatic flow Decrease in systemic nervous tension and general or local muscle spasm VIBRATORY THERAPY INDICATIONS A large number of musculoskeletal ailments can be effectively treated with vibratory therapy. See Table II for listed indications VIBRATORY THERAPY TREATMENT DURATION of the G-5/G-3’s strong effect and deep penetration, it is not advisable to use the unit too long over an isolated site. Overuse can produce tissue inflammation and symptoms of soreness. Because VIBRATORY THERAPY TREATMENT DURATION As with most therapies, proper therapy duration depends on the patient’s condition and tolerance to the modality General guidelines for treatment time are shown in table IV. VIBRATORY THERAPY If the patient reports a strong “itchy” sensation, the treatment should be stopped. This sensation is invariably due to excessive stimulation of cutaneous and subcutaneous receptors, often with progressively adverse vasomotor consequences VIBRATORY THERAPY PRECAUTIONS Prior to application, be sure that the attachments are securely fastened to the applicator head so that they will not disconnect during therapy, and assure that the cable does not become kinked. VIBRATORY THERAPY PRECAUTIONS Because the unit is designed to operate against pressure, it should not be allowed to run extensively when not applied. Avoid sliding the applicator back and forth over the spinal column or bony prominences, and don’t move the applicator too fast. VIBRATORY THERAPY PRECAUTIONS Always work toward the heart, in the direction of venous and lymph flow, when the extremities are being treated. Because of the deep penetration produced by the unit, there is no need to apply heavy pressure while moving the applicator. VIBRATORY THERAPY PRECAUTIONS Excessive pressure or moving the unit too fast may cause patient discomfort and/or bruise the patient’s skin. Use of a dry towel at the applicator - skin interface prevents body oils and perspiration from contaminating the attachment and prolongs the life of the attachment. VIBRATORY THERAPY PRECAUTIONS The towel also contributes a dispersive cushioning factor. It is not a good procedure to allow excessive vibration to the operator’s hand over prolonged periods, day after day. VIBRATORY THERAPY PRECAUTIONS There has been cases of unilateral hypertrophic arthritis in barbers who routinely used a small handattached vibrator to stimulate customers scalps after shampooing. THE END
