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CHIROPRACTIC
PHYSIOLOGICAL
THERAPEUTICS
COURSE # 7121
DR. GRANT
REQUIRED TEXTBOOK
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.
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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.
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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.
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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. Medium Frequency
.
Interferential current
.
Russian Stim.
 5. Low frequency currents.
 6. Direct current (galvanic).
 7. High voltage current.
 8. Alternating current
1.
Sine wave
2.
Faradic current
3.
TENS
4.
Muscle stimulators

BASIC FORMS
 9.
Hydrotherapy
 10.Exercise therapy
 11.Rehabilitative therapy
 12.Meridian therapy
A . Pressure techniques
B . Acupuncture
C. Auricular therapy
D. Ryodoraku or Akabane
E . Laser
BASIC FORMS
 13.Vibratory
therapy
 14.Traction and stretching
 15.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
 . Method of application
 . Patient position
 . Timing
GENERAL CONSIDERATIONS
C .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
Terminating the therapy
treatment
After removing electrodes from the
patient.
 3.
A . Turn off the unit
B . Dry and check the patient’s skin
C. Check the patient for dizziness, nausea,
and faintness
D. Ready the patient for the adjustment
GENERAL CONSIDERATIONS
Precautions and complications:
Immediately note any signs of
burns or any other problems and
take appropriate action.
 4.
GENERAL RULES
 Be
sure you know what your confronted
with (i.e..; symptoms, conditions,
pathophysiology involved).
 Choose 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..)
TREATMENT PROCESS
 The
primary goal of any form of therapy,
whether it be manipulation, medication,
electrotherapy, heat and cold, is to
stimulate the body to perform a specific
function.
 In order to select the most appropriate
form of therapy, it is imperative that the
clinician recognize the particular
physiologic needs of the patient’s
condition.
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TREATMENT PROCESS
 In
addition, the clinician must appreciate
the psychological and emotional needs
and makeup of the individual patient to
be treated.
 Consideration must be given to the
contraindications for treatment and to
patient safety.
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TREATMENT PROCESS
 Finally,
in the changing health care
environment, the clinician must consider
the cost effectiveness of various
treatment procedures.
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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
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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.
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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.
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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
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treatment must be recognized.
INDICATIONS AND
CONTRAINDICATIONS
 Indications
- Those factors that
specifically indicate the application of a
particular modality. (Ice for swelling)
 General contraindications - Include a
variety of relatively common conditions
in which the use of certain modalities
may be unwise; for instance, diabetes
and pregnancy. Each of these
conditions adds elements that
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complicate the treatment process.
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.
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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.
 The patient should be informed of the
following :
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INFORMED CONSENT
 1.
Diagnosis
 2. Nature and purpose of the proposed
treatment.
 3. Known risks and consequences of
the proposed treatment excluding
those eventualities that are too
remote and improbable to bear
significantly on the decision process
of a reasonable person are too well
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known to require statement.
INFORMED CONSENT
 4.
Benefits to be expected from
proposed treatment, with an
assessment of the likelihood that the
benefits can be realized.
 5. All alternative treatments that might
reasonably be used, including all the
information provided above which
must be given for the alternatives as
well.
 6. Prognosis if no treatment is given. 32
INFORMED CONSENT
 7.

All costs, including the amount and
duration of pain generally involved,
the potential impact on lifestyle and
ability to resume work, and the
economic costs of both the treatment
and aftercare.
NOTE: The patient should be told if
insurance will cover the bills.
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PT.. OBJECTIVES
Increasing
and maintaining strength
and endurance
Increasing coordination
Decreasing pain
Decreasing muscle spasm
Decreasing swelling
PT. OBJECTIVES
Decreasing
chest congestion
Correcting postural deviations
Promoting the healing of soft tissue
lesions
Preventing contractures and
deformities
Increasing range of motion in joints
STAGES OF HEALING
Inflammatory
Stage
Reparative stage
Toughening stage
INFLAMMATORY STAGE
Where
white blood cells dissolve
extravasated blood elements and
tissue debris, characterized by
swelling and local tenderness.
REPARATIVE STAGE
Where
the network of fibrin and the
fibroblasts begin the reparative
process, characterized by local
heat, redness, and diffuse
tenderness.
TOUGHENING STAGE
Often characterized by palpable
thickening and induration in the
area of reaction, with tenderness
progressively diminishing.
The greater the bleeding, the more
acute and diffuse the inflammatory
state, and greater induration and
fibrous thickening can be
anticipated.
USE OF THERAPEUTIC
MODALITIES
 The
judicious and timely use of
therapeutic modalities and techniques
tailored specifically to the individual
patient’s condition, can radically alter
the events that follow:
 For example, clinicians are in an
excellent position to prevent the
development of chronic edema.
THERAPEUTIC TOOLS
 Some
powerful therapeutic tools
available to clinicians include: cold,
heat, electricity, biofeedback,
compression, and massage, commonly
known as therapeutic modalities.
 Application of the appropriate modality
at a particular stage of the healing
process can prevent prolonged period
of convalescence.
CRYOTHERAPY
CHAPTER NINE
Pages 209-215
THEAPEUTIC COLD
 Therapeutic
cold, is used in the
management of acute and chronic
injuries.
 When applied to the human body,
Cryotherapy elicits a number of
physiologic responses.
 These responses vary somewhat
according to the situation in which
Cryotherapy is used, but they can be
summarized as follows:
PHYSIOLOGICAL
RESPONSES TO
THERAPEUTIC COLD
 Decreased
temperature
 Decreased cellular metabolism
 Decreased pain
 Decreased muscle spasm
 Increased tissue stiffness
 Increased or decreased inflammatory
effects
THERAPEUTIC COLD
RESPONSES
 Increased
or decreased circulatory
effects.
 Additional effects of Cryotherapy relate
to muscle strength and proprioception.
CELLULAR METABOLISM
 Cellular
processes proceed more slowly
at lower temperatures. Therefore
Cryotherapy acts to slow the rate of the
chemical reactions that occur as part of
tissue metabolism.
 In addition, cold acts to inhibit the
release of histamine.
CELLULAR METABOLISM
 After
an injury, damaged cells stimulate
the release of histamine, a potent
vasodilator that dramatically increases
blood flow to an area.
 The histamine response is then
maintained by mast cells
 The net effect of this process is the
edema itself is not harmful to the body,
it can slow the exchange of nutrients
and cellular waste.
CELLULAR METABOLISM
 Increases
in intracellular pressure
caused by edema can also contribute to
cellular anoxia.
CRYOTHERAPY & PAIN
 Cryotherapy
is the modality of choice in
the initial treatment of an acute injury
primarily because of its role in
decreasing cellular metabolism.
 In addition, cold is an effective pain
reliever, a property that is of clinical
importance in the treatment of acute
injury and in injury rehabilitation.
CRYOTHERAPY & PAIN
Although the precise mechanism by which
the application of cold reduces pain is not
known, speculation implicates one of two
processes or, possibly a combination of
these.
 It is believed that cold modalities relieves pain
by slowing and reducing the number of pain
impulses sent by the peripheral nerves and
by interfering with the transmission of those
impulses to the brain.

MUSCLE SPASM
 Several
theories have been proposed to
explain the reduction of muscle spasm
through the application of cryotherapy.
 Because of a decrease in nerve
conduction velocity, cryotherapy
reduces the amount of sensory nerve
activity and, hence, the resultant motor
nerve activity that triggers and
maintains spasms.
MUSCLE SPASM
 A more
complex spasm reduction
mechanism that involves reflexes also
appears to be at work.
1 . The decrease in reflex responses soon
after the application of cold
2 . The relationship between cutaneous
cooling and decreased tonic stretch
reflexes
3 . The decrease in muscle spindle activity
during stretching after sympathetic
stimulation.
TISSUE STIFFNESS
 The
stiffness of the soft tissues of the
body is increased with the application of
cryotherapy. These tissues are less
elastic and more resistant to movement.
 Cryotherapy in combination with
stretching assists in the reduction of
muscle spasm, but attempts to increase
the length of a cooled muscle could
result in tearing of tissue.
INFLAMMATION
 Studies
on inflammation have shown
cryotherapy to mitigate, activate, or
hamper the process in different
situations.
 Cold can stimulate prostaglandin
mediated inflammation and inhibit
inflammation that is thought to be
similar to traumatically induced
inflammation.
CIRCULATION
 Although
cryotherapy leads to
vasoconstriction, in the setting of acute
injury, ice is usually not applied until
vasoconstriction is initiated in the body
as part of the acute inflammatory
response. Therefore, the circulatory
effects of cryotherapy on acute injuries
are not significant.
PROPROCEPTION
 Various
authors concluded that cooling
has no impact on proprioception or
motor activity after a 20 minute ice
immersion test on several athletes.
MUSCLE STRENGTH
 Cold
has been reported to increase
isometric muscular strength.
 Measures of strength taken immediately
after a 30 minute submersion of a leg
into a cold bath have revealed strength
to be significantly diminished.
 Measures taken after this period,
however, showed that muscle strength
increased and eventually exceeded
pretreatment levels.
MUSCLE STRENGTH
 In
both studies, strength of the cooled
muscle tissue began to exceed
precooled or normal levels at 60 to 80
minutes after removal from the cold
modality and it was maintained at
remarkably high levels up to 180
minutes.
 Authors conclude however that these
results do not support the position that
the application of cold results in strength
increases.
CONSIDERATIONS FOR USE
 In
using cold modalities, the clinician
must consider ways to avoid
undercooling, which does not achieve
the desired result, and overcooling,
which risks tissue damage.
 The application of cold to superficial
areas can result in excessive cooling of
nerve tissues that are especially
vulnerable to the effects of local cooling.
CONSIDERATIONS FOR USE
 Drez
and associates have reported five
patients with nerve palsy secondary to
cryotherapy, one of whom had not
spontaneously recovered by 9 months
after injury.
CONSIDERATIONS FOR USE
 They
recommend that ice not be
applied for more than 20 minutes, with
30 minutes being the absolute
maximum length of treatment, and that
areas of tissue in which superficial
nerves are located be avoided
altogether.
CONSIDERATIONS FOR USE
 Finally,
the clinician should exercise
caution in applying cold directly over
open wounds during the first 2 to 3
weeks of healing because studies
reported that this practice significantly
reduces the tensile strength of the
wound.
 Cold diminishes the rate of metabolic
processes, thus slowing the rate of scar
formation and healing
INDICATIONS
 Knowledge
of the physiologic effects of
cold modalities helps determine the
types of conditions of which cryotherapy
is indicated.
 Therapeutic use of cold is clearly an
excellent choice in treating acute
trauma. it helps prevent secondary
hypoxic injury, controls the formation of
edema, and is an outstanding pain
reliever.
THERAPEUTIC HEAT
Pages 169-232
THERAPEUTIC HEAT
 Specific
modalities of therapeutic heat
can appropriately be divided into two
classes of heating agents : superficial
and deep.
 The deep heating agents, however,
have some unique differences, both in
the effects they produce and in the
energy sources they use, and hence
represent a separate class.
SUPERFICIAL HEATING
MODALITIES
 Superficial
heating agents are similar in
certain ways to therapeutic cold
modalities.
 Because both modalities are applied
externally, they have similar physiologic
effects, although the direction of heat
transfer is reversed because the heating
agents are warmer than the body.
SUPERFICIAL HEATING
MODALITIES
 The
physiologic responses to superficial
heat can be categorized as follows:
1 . Increased temperature
2 . Vasodilation
3 . Increased cellular metabolism
4 . Decreased pain
5 . Diminished muscle tone and spasticity
6 . Decreased joint stiffness
TISSUE TEMPERATURE
 Superficial
heating agents, when
applied to the body, produce only mild
increases in tissue temperature.
 Generally, when a superficial heating
agent is applied to the body, internal
temperatures rise gradually and do not
exceed 104 degrees F and the duration
of temperature elevation at its peak
level is relatively short
CIRCULATION
 An
elevation in tissue temperature
elicits an increase in local blood flow.
 This occurs primarily in the vessels of
the skin and subcutaneous tissues.
 Vasodilation occurs not only in the area
being heated but also in tissues distant
from the heating agent through
concensual or indirect vasodilation.
CELLULAR METABOLISM
 The
increase in local blood flow not only
cools the tissues by drawing heat away
to other areas of the body, where it can
be dispersed, but also brings greater
than normal amounts of oxygen and
nutrients into the area.
 The rates of chemical reactions,
especially those of cell metabolism, are
dramatically increased by the rise in
temperature.
CELLULAR METABOLISM
 Thus,
a sudden and large demand for
both oxygen and nutrients is made by
the cells.
 If this demand is not satisfied
adequately, the cells die.
 Heating modalities are therefore
always contraindicated for tissues with a
restricted blood supply.
CELLULAR METABOLISM
 Damaged
tissues in the process of
healing also increase the rate of their
cellular processes, which, it is hoped,
speeds their rate of repair.
PAIN AND MUSCLE SPASM
 It
is thought that superficial heating
agents act to relieve pain and diminish
muscle spasm in the same way as do
the cold modalities.
 Two authors have cited numerous
studies indicating that muscle tone is
decreased by the topical application
of heat.
PAIN AND MUSCLE SPASM
 The
reduction of muscle tone with heat
is widely known and accepted from the
muscle-relaxing effects of a hot shower,
heating pad or Jacuzzi.
 Also, topically applied heating agents
stimulate the activity of skin
thermoreceptors.
JOINT STIFFNESS
 Finally,
the topical application of
heating agents decreases joint
stiffness.
 This effect, in combination with the mild
pain-relieving and vasodilation
properties, makes superficial heat an
ideal modality to use prior to
exercise.
INDICATIONS
 The
use of superficial heating agents is
indicated: (1) whenever a mild
increase in blood flow, (2) Increased
speed of healing, (3) Partial relief of
pain, (4) Relaxation of muscles, or (5)
Decreased joint stiffness is desired.
INDICATIONS
 In
conditions such as:
 relief of painful muscle spasms,
 nonacute muscle contusions,
 and tight joint capsules,
 superficial heating modalities can be
useful components of the treatment
regimen.
IDICATIONS
 The
clinical use of hot packs, whirlpools,
paraffin baths, contrast baths and
fluidotherapy is usually related to their
pain-relieving and joint pliabilityinducing properties.
 Alterations in blood flow by superficial
heating agents are restricted to the skin
and subcutaneous tissues.
THERAPEUTIC ELECTRICITY
CHAPTER FOUR
Pages 51-117
THERAPEUTIC ELECTRICITY
 Electrical
stimulators have become
more user-friendly and thus has
increased in popularity for the practicing
clinician.
 It has become easier to punch the
manufacturer’s preset buttons, losing
sight of what the modality is actually
capable of treating.
THERAPEUTIC ELECTRICITY
 Most
manufacturers have preset values
for treating swelling, yet scientific
evidence that electrical stimulation has
any impact on acute swelling in the
clinical setting is essentially nonexistent.
BASIC CONSIDERATIONS
 Despite
the various names, only three
types of electrical current are applied to
biologic tissues:
1 . Direct current
2 . Alternating current
3 . Pulsed current
BASIC CONSIDERATIONS
 Direct
current (DC) is a continuous, one
directional flow of charged ions and is
sometimes known as galvanic current.
 Alternating current (AC) is a continuous,
two directional flow of charged ions and
may be referred to as faradic current.
 Pulsed current is a flow of ions that is
periodically discontinued for a finite
period of time, and the flow can be
unidirectional or bi-directional.
BASIC CONSIDERATIONS
 Most
clinical stimulators produce some
form of pulsed current.
 Understanding how pulsed current is
different from DC or AC lies in the
periodic interruption (interpulse interval)
of the current flow.
BASIC CONSIDERATIONS
 The
interval allows for independent
adjustment of frequency and phase
duration in pulsatile units that is not
possible in AC or DC generators
because they lack this interval.
 Pulsed current actually looks the same
as DC or AC, except that it is cyclically
interrupted.
BASIC CONSIDERATIONS
 Pulsed
currents are described by their
waveforms.
 They can be monophasic (each pulse
contains one phase), in which deviation
from the baseline occurs in one
direction only, or biphasic (each pulse
contains two phases), in which the
deviation from the baseline occurs in
two directions.
BASIC CONSIDERATIONS
 The
phase can be symmetric or
asymmetric depending on whether the
sizes of the two phases are equal.
 A third type of pulsed current is
polyphasic, in which each pulse
contains three or more phases.
BASIC CONSIDERATIONS
 This
waveform (polyphasic) is referred
to by many different names, some of
which include burst, AC, medium
frequency stimulation, and carrier
frequency.
PULSE FORMS
BASIC CONSIDERATIONS
 Once
a specific current has been
identified as direct, alternating, or
pulsed, with monophasic, biphasic, or
polyphasic waveforms, symmetric or
asymmetric, additional terms can be
used to describe the phases of a pulse
and the pulses themselves.
TERMINOLOGY
 Peak
amplitude: the maximum value a
current can reach in a monophasic
current or in either phase of a biphasic
current.
 Phase duration: the length of time
during which a single phase of he
current is applied.
 Pulse duration: the time from the
beginning to the end of a single pulse.
TERMINOLOGY
 In
regards to pulse duration, sometimes
the term “pulse width” is used to denote
this.
 To make things confusing phase
duration is sometimes used for pulse
duration.
 Intrapulse interval: the time lapsed from
one phase of a pulse to the next
(interphase interval)
TERMINOLOGY
 Interpulse
interval: the time between
pulses
 Frequency: the number of pulses that
occur in 1 second.
 Rise time: the time during which current
of a phase increases from zero at the
baseline to the peak amplitude.
TERMINOLOGY
 Decay
time: the time during which the
current of a phase decreases from peak
amplitude to zero.
 Similarly, the current itself can be
altered in this manner through ramping.
 Current can be ramped up or down by
increasing or decreasing current
intensity, length of the pulse duration, or
pulse frequency.
BASIC CONSIDERATIONS
 Electrical
current is passed into the
body through electrodes and a
conducting medium. (water, electrolyte
gel, conductive polymers)
 Each channel of a stimulator has two
leads, both of which are essential to
current flow.
 A common mistake is to call one lead a
ground.
BASIC CONSIDERATIONS
 A ground
is used to safely remove
excess current from a stimulator; no
such mechanism is attached to the
patient.
 Although electrodes can be arranged in
numerous configurations, they can be
categorized as one of two placement
techniques: monopolar and bipolar
BASIC CONSIDERATIONS
 In
a monopolar arrangement, one lead
with its electrode or electrodes is placed
in the target region (region in which the
patient should perceive the strongest
sensation of current).
 The electrode or electrodes from the
other lead are placed in a non-target
area ( an area in which the patient will
perceive little or no sensation of current)
BASIC CONSIDERATIONS
 The
way the current perception is
modified to allow for strong sensation at
the target site and little or no sensation
at the non-target site is through the
manipulation of current density.
 Current density is defined as the
amount of current divided by the contact
surface area of the skin-electrode
interface.
BASIC CONSIDERATIONS
 The
higher the current density, the
greater the perception of current.
 Therefore, in the typical monopolar
electrode technique, one lead is
usually attached to a rather large
electrode, whereas the other lead is
attached to one or two electrodes
that are significantly smaller.
BASIC CONSIDERATIONS
 The
large electrode with its large skinelectrode interface area has a relatively
low current density and thus provides
little if any sensation of current
compared with the smaller electrode or
electrodes on the other lead.
 The smaller electrodes have a larger
current density, and therefore, the
current is perceived as being much
more intense under them.
BASIC CONSIDERATIONS
 Bipolar
arrangements involve the use of
electrodes of the same or similar size
on both leads.
 Electrodes from both leads are typically
placed in target areas.
 With the multichannel stimulator units
available currently, the term “quadripolar
electrode arrangements” is often used.
BASIC CONSIDERATIONS
 This
arrangement is nothing but the use
of two channels, each with a bipolar
electrode technique.
GUIDELINES FOR VARIOUS
INPUT PARAMETERS
 Because
the most frequent use of ES is
for stimulation of excitable tissue, we
need some basic guidelines for
choosing parameters on the basis of the
treatment goal.
POLARITY
 The
ability to make polarity choices is
found in stimulators that produce
monophasic pulsed current, asymmetric
unbalanced biphasic pulsed current, or
DC.
 Of these, by far the most typical current
form generated by clinical units is the
monophasic pulsed form.
POLARITY
 When
electrical stimulation is being
used for pain control, polarity of the
electrodes has little impact on the
effectiveness of the stimulation.
 If muscle stimulation is the desired goal,
the importance of the polarity depends
on the chosen electrode technique.
POLARITY
 If
a bipolar electrode technique is used
with the electrodes placed on the
proximal and distal ends of the muscle
belly, polarity is not a factor in the
strength of the stimulated contraction.
 If a monopolar electrode technique is
used, the electrodes in the target area
should be made negative.
POLARITY
 This
will allow for a stronger contraction
at any given current amplitude
compared with the contraction strength
obtained with positive target area
electrodes.
 DC is primarily used for iontophoresis.
The polarity chosen for the medication
containing electrode will depend on
whether the medication is a positive or a
negative ion.
WAVEFORM
 Some
pulsed current stimulators allow
the clinician to choose among
monophasic, biphasic, or polyphasic
waveforms as well as among different
shapes of these forms.
 The choice of waveform and shape is
directed more by individual patient
comfort than by any other element.
WAVEFORM
 Patients
will typically find one
particularly waveform more comfortable.
 There is no single waveform that all
patients will find the most comfortable.
 The ability to try different waveforms
allows the clinician to find one that is
most comfortable, which can facilitate
achieving the desired treatment
response.
GUIDELINES FOR VARIOUS
INPUT PARAMETERS
 Because
the most frequent use of ES is
for stimulation of excitable tissue, we
need some basic guidelines for
choosing parameters on the basis of the
treatment goal.
STRENGTH (intensity) AND
DURATION PARAMETERS
 The
intensity is one of the most
important parameters that control
whether the desired response is
achieved.
 Does the patient feel any current at all?
If not, it is considered subsensory.
 Does the patient feel a strong but
comfortable tingling sensation?
STRENGTH (intensity) AND
DURATION PARAMETERS
 If
so, this is considered the sensory
level.
 Is the stimulation producing a visible
muscle contraction or motor response?
 Motor responses can be categorized as
minimal, moderate or maximally
tolerated motor response.
 Finally, is the stimulation causing an
uncomfortable or painful response?
STRENGTH (intensity) AND
DURATION PARAMETERS
 If
this is the case, this is considered the
noxious level.
 Sensory, moderate motor, and noxious
intensities are typically used for pain
control.
 Minimal to moderate motor intensity
levels can be used in much the same
way a biofeedback unit can be used for
muscle re-education.
STRENGTH (intensity) AND
DURATION PARAMETERS
 Maximally
tolerated motor intensity level
is used if the desired response is
muscle strengthening.
 Shorter phase duration's are typically
used for sensory level pain control,
whereas longer phase duration's are
used for muscle contractions and for
noxious level pain control.
FREQUENCY
 Frequency
does not determine whether
an action potential is generated in an
excitable tissue.
 The purpose for adjusting frequency is
to control how many times per second
the action potential is generated, once
the intensity and phase duration are
sufficient to cause an action potential.
FREQUENCY
 Example;
if the frequency is set at 100
Hz and the intensity and phase duration
are sufficient to depolarize the nerve,
that nerve will produce 100 action
potentials each second.
 The choice of treatment frequency is
then determined by how many action
potentials are desired every second,
which in turn is guided by the treatment
goal.
FREQUENCY
 At
motor level stimulation, a frequency
of 1 pulse per second will produce a
muscle twitch.
 As the frequency is increased, the
twitches will occur closer together until
they fuse into a smooth, tetanized
contraction.
 The frequency at which this fusion
occurs in most cases will be between 15
and 30 pps, varying with the muscle
selected
Physiologic Effects

Generally, therapeutic electricity has
been used for the maintenance or gain
of muscular strength, relief of pain,
reduction of edema, delivery of
medication transcutaneously, and
healing of chronic wounds and
nonunion fractures.
ELECTRICAL STIMULATION
DEVICES
CHAPTER FIVE
Pages 73-133
Pain Alliance Institute
121
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)
 Another is the amount of voltage that
may be produced (Low voltage or High
voltage)
 Finally by reference to some unique
aspect of the current that is used (IF,
Russian Stim.)
122
LOW VOLTAGE AC
STIMULATORS
 These
devices typically use a biphasic
(AC) sinusoidal waveform.
 They can deliver a maximum of 150
volts.
 They were one of the more common
forms of electrical stimulator.
HIGH VOLTAGE
STIMULATORS (HVG)
 A stimulator
that uses a high voltage
with a direct current.
 They can deliver up to 500 volts
 These stimulators use high voltage and
extremely short pulse width, which
enables them to overcome skin
resistance; they penetrate deeply and
provide a relatively comfortable stimulus
TENS
 Is
usually associated with small, patient
held, battery-operated units that are
used for outpatient pain control.
 They use either AC or DC currents, but
all of the small devices that are provided
for patients for home care use a direct
current, usually run by a 9 volt battery.
MICROAMPERAGE
STIMULATION DEVICE
 These
devices use subthreshold current
 They usually are associated with
devices designed to promote tissue
healing.
 They are not used to stimulate nerves
as do more traditional forms of electrical
stimulation.
 They may provide the most promising
form of electrical stimulation.
INTERFERENTIAL
STIMULATORS
 These
stimulators use medium
frequency and an alternating current
(AC)
 They use two low voltage currents that
are designed to intersect and “interfere”
 The high “carrier “ frequency found with
IF stimulators overcomes skin
resistance and allows the machines to
penetrate deeply and provides a
relatively comfortable stimulus.
LOW VOLTAGE GALVANIC
STIMULATION DEVICES
 They
use a low voltage, nonpulsed,
direct current.
 Therapeutic uses are limited to
iontophoresis and electrodiagnosis.
 Because of the particular nature of this
type of current, it is potentially the most
harmful type of electrical stimulation
 They are not usually considered a very
comfortable form of ES.
ELECTROTHERAPY USAGE
CAUTIONS
Current
density - This is the amount
of current being delivered to the
patient divided by the area through
which the current is being delivered
(the surface area of the pads being
used.
Generally speaking, the lower the
current density, the better
129
ELECTROTHERAPY USAGE
CAUTIONS
Pad
condition - Worn or dried out
pads cause the current to
concentrate in small areas of the
pad instead of going into the skin
and then distributed evenly
throughout the entire pad surface.
130
ELECTROTHERAPY USAGE
CAUTIONS
This
has the effect of increasing the
current density, since the current is
being delivered through a smaller
area.
CARBON PADS
ELECTROTHERAPY USAGE
CAUTIONS
Patient
susceptibility - Some
patients skin is more sensitive to
electrotherapy currents. this can
cause a reaction similar to heat
rash.
133
ELECTROTHERAPY USAGE
CAUTIONS
Electrotherapy
causes increased
blood flow, especially under the
pads. In some patients, this can
cause accumulation of fluids just
under the skin, resulting in a rash,
burn, or blister.
134
ELECTROTHERAPY USAGE
CAUTIONS
This
tendency can be minimized by
using only a moderate current.
It is not necessary to raise the
treatment intensity to just short of
the patients pain threshold to
achieve adequate results.
135
ELECTROTHERAPY USAGE
CAUTIONS
Use
as large a pad as is practical
for the application.
For carbon electrodes , the
recommended intensity for a 3 inch
round pad is 25 - 30. For a 3 x 5
inch pad the recommended
intensity is 30 to 40.
136
ELECTROTHERAPY USAGE
CAUTIONS
For
Self-adhesive pads, the
recommended intensity for a 1.25
inch round pad is 10 - 12. For a 2
inch round pad the recommended
intensity is 10 -20. For a 3 inch
round pad the recommended
intensity is 25 - 30
137
ELECTROTHERAPY USAGE
CAUTIONS
Ensure
that the area on the
patient’s skin where the pad is to
be placed is clean and free of all
foreign matter. This includes
powder, perfumes, and the like, as
well as body oils or dirt or grime.
138
ELECTROTHERAPY USAGE
CAUTIONS
Iontophoresis
occurs with all
electronic therapies, and can drive
any of the above surface
contaminants below the epidural
layer, where an allergic reaction
may occur.
139
ELECTROTHERAPY USAGE
CAUTIONS
 Make
sure that the pads being used are
in good shape. The poly-adhesive pads
should have good adhesion over the
entire surface area of the pad.
 The area where the leads attach to the
pad should not be damaged such that
the connection to the foil backing behind
the adhesive is broken.
140
ELECTROTHERAPY USAGE
CAUTIONS
Patients
who are sensitive to
electrotherapy treatments, treat
with reduced intensity and/or
shorter treatment times, with
possibly more frequent treatments,
if required.
Check patient leads every time you
connect them to the patient.
141
SELF ADHESIVE
ELECTRODES
To
restore adhesiveness: Prior to
placing the electrode on the patient,
moisten the patients skin with a
damp cloth using plain water, then
apply the electrode to the skin.
142
SELF ADHESIVE
ELECTRODES
After
a treatment: Spray the
adhesive side of the electrode with
plain water, re-apply the electrode
to its plastic backing and seal it
tightly in its storage pouch.
143
SELF ADHESIVE
ELECTRODES
After
a treatment: Soak the
electrode in warm water for up to 2
minutes, then place it on the
backing and return to the sealed
pouch (shake off the excess water
before applying to the backing).
144
SELF ADHESIVE
ELECTRODES
With
this method of rehydration,
after a couple of hours electrodes
can regain up to 90% of their
original adhesive quality.
NEVER use a self adhesive
electrode for more than 15
treatments (maximum).
145
SELF ADHESIVE
ELECTRODES
Never
use straps, weights, or other
devices to attach self-adhesive
electrodes to the skin. If an
electrode has lost its adhesive
quality, you can use one of the
methods given to rehydrate the
adhesive, or you should discard the
electrode.
146
HIGH VOLT THERAPY
DR. GRANT
147
Pain Alliance Institute
HIGH VOLTAGE CURRENT
DEFINITION
This
is a current in which the
waveform has an amplitude of
greater than 150 V with a relatively
short pulse duration.
TERMINOLOGY
A volt
is the electromotive force that
produces a movement of electrons;
Commercial current flowing from
wall outlets produce an
electromotive force of either 115 V
or 220 V.
An ampere is a unit of
measurement that indicates the
rate at which electrical current is
flowing.
TERMINOLOGY
In
the case of therapeutic
modalities, current flow is generally
described in milliamperes (1/1,000
of an amp), or in microamperes
(1/1,000,000 of an amp).
TERMINOLOGY
The
term pulse is synonymous with
waveform, which indicates a
graphic representation of the
shape, direction, amplitude,
duration, and pulse frequency of
the electrical current being
produced by the electrotherapeutic
device, as displayed by an
instrument called an oscilloscope.
HIGH VOLTAGE THERAPY
HV
is a unidirectional, pulsed
current of up to 500 V force and
average current of 1.0 - 1.5 mA.
Pulsed duration is generally
between 20 and 200 microsec.
The duration of each pulse
indicates the length of time that
current is flowing in one cycle.
152
HIGH VOLTAGE THERAPY
In
the past, it has been customary
to refer to these stimulators as
“high voltage galvanic stimulators”;
this inaccurate use of the term
“galvanic” has led many to claim a
significant polarizing effect for HVG
machines.
HIGH VOLTAGE THERAPY
Although
these stimulators use DC,
there is only a minimal polarizing
effect and they are not capable of
iontophoresis.
HIGH VOLTAGE THERAPY
The
term galvanic refers to a
continuous, nonpulsed current that
is used for iontophoresis
HIGH VOLTAGE THERAPY
The
traditional term “high voltage
galvanism” is somewhat
misleading, as clinicians tend to
confuse and /or equate the effects
of HVT with low-voltage galvanism.
156
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.
157
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.
158
HIGH VOLTAGE THERAPY
EFFECTS
Analgesia
Edema
absorption
Muscle contraction
Increased peripheral circulation
159
HIGH VOLTAGE THERAPY
INDICATIONS
Soft
tissue injuries
Sciatica
Arthritic conditions
Nonsystemic edema
Muscle spasm, muscle reeducation
Trigger Point therapy
160
HIGH VOLTAGE THERAPY
CONTRAINDICATIONS
Malignancy
Patients
with pacemakers
Pregnancy
Over open wounds
Transcerebrally
Cardiac conditions
161
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.
162
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.
163
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.
165
LOW VOLTAGE THERAPY
Low
frequency alternating current :
a current in which the direction of
electron flow changes at a rate
between 1 and 2000 Hz.
Sine wave: a low frequency
alternating current that takes the
shape of a sine curve
Faradic current: a low frequency
alternating current with 2 unequal
phases
166
LOW VOLTAGE THERAPY
EFFECTS
Contraction
of enervated muscle
Pain
relief
Edema reduction
167
LOW VOLTAGE THERAPY
INDICATIONS
Stimulation
of weak and/or
atrophied muscles
Nonsystemic edema
168
LOW VOLTAGE THERAPY
CONTRAINDICATIONS
Through
the brain, heart or eyes
Over bony prominences
Fractures
Skin lesions
Malignancy
Anesthetic areas
Over a gravid uterus
169
LOW VOLTAGE THERAPY
Application
Place
pads firmly on treating parts;
can use hot packs for combination
therapy.
Monopolar, quadrapolar or bipolar
techniques may be used.
If unequal sized pads (monopolar)
are used, the smaller pad (active
pad) will produce a greater effect.
170
LOW VOLTAGE THERAPY
APPLICATION
A probe
may be used for specific
stimulation of motor points.
Set mode to: Pulse, if a gentle
treatment is desired, to avoid
further trauma or to disperse fluid.
Set mode to: Surge, if a series of
muscle contractions is desired
(e.g.., for muscle re-education)
171
LOW VOLTAGE THERAPY
APPLICATION
Set
mode to: Tetanize, if a tetanic
contraction is desired to fatigue the
muscle (e.g.., for muscle spasm or
muscle tension)
Choose the pulse width, “on ramp”
time, and/or “off ramp” time.
Set the timer to desired time
172
LOW VOLTAGE THERAPY
APPLICATION
Increase
the intensity slowly to
patient tolerance or until the
desired muscle contraction is
achieved.
Treatment duration depends on the
effect desired and the integrity of
the muscle being stimulated
173
LOW VOLTAGE THERAPY
APPLICATION
Dr.
Kots of the Soviet Union has
suggested the following times:
To increase circulation: 2 sec on, 2
sec off
To reduce spasm and pain: 12 sec
on, 8 sec off
For strength endurance, and
velocity: 10 sec. on, 50 sec. off
174
Low Voltage Therapy
Summary
 LVT
is used primarily for muscle
contraction in a enervated muscle.
 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 (pps).
Low Voltage Therapy
Summary
 At
one pps, the muscle will contract and
relax once per second.
 As the frequency (pps) is increased, the
muscle pumps faster until you reach a
stage where the muscle is incapable of
relaxing before the next electrical pulse
arrives (tetanized contraction, 35 pps)
 As you progress beyond this point (>35
pps), the contraction becomes stronger.
Low Voltage Therapy
Application
 1.
Prepare the patient by placing the
pad electrodes over the area to be
treated. (make sure the intensity
control is set at “0/Reset”.
 2. Select the desired output mode by
turning the control knob to Surge,
Tetanize or Pulsation. Do Not adjust
the Intensity Control at this time.
Low Voltage Therapy
Application
 3.
Set the timer to the desired
treatment duration.
 NOTE: Initially turn the timer clockwise
PAST THE 10 MINUTE mark for proper
timer operation. You may then turn the
timer knob back if the desired setting is
less than 10 minutes.
 The
“On” panel lamp will illuminate
indicating that the unit is functioning.
Low Voltage Therapy
Application
 The
Pulsation Rate Indicator Lamp will
illuminate when the output mode control
is set at Tetanize or pulsation.
 The Surge Rate Indicator Lamp and the
Pulsation Rate Lamp will illuminate
when the output mode control is set at
Surge.
 4. Slowly increase the intensity to the
desired level.
Low Voltage Therapy
Application
 To
operate Pulse/Surge Rate Control,
the Output Mode Control must be set at
either Surge or Pulsation.
 5. Before repositioning or removing the
electrodes, always reduce the
intensity control to “0” by turning the
controls COUNTERCLOCKWISE
IONTOPHORESIS
CHAPTER SIX
Pages 134-143
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
 Neither
high-voltage direct current or
interferential currents may be used for
iontophoresis since the current is
interrupted and the current duration is
too short to produce significant ion
movement.
 Recommended current amplitudes used
for iontophoresis range between 3 and
5 mamp.
IONTOPHORESIS
 Recommended
treatment durations
range between 10 and 20 minutes, with
15 minutes being average.
 During this 15 minute treatment, the
patient should be comfortable with no
reported visible signs of pain or burning.
 The doctor should check the patient’s
skin every 3-5 minutes during treatment,
looking for signs of skin irritation.
IONTOPHORESIS
 Since
skin impedance usually
decreases during the treatment, it may
be necessary to decrease current
intensity to avoid pain or burning.
IONTOPHORESIS
ELECTRODES
 The
commercially produced electrodes
are sold with most iontophoresis
systems.
 These electrodes have a small
chamber, into which the ionized solution
may be injected, that is, covered by
some type of semipermeable
membrane.
 The electrode self-adheres to the skin.
IONTOPHORESIS
ELECTRODES
 This
type of electrodes has eliminated
the “mess and hassles” that have been
associated with electrode preparation
for iontophoresis in the past.
 Once the electrode has been prepared.
It then becomes the active electrode,
and the lead wire to the generator is
attached such that the polarity of the
wire is the same as the polarity of the
ion in solution.
IONTOPHORESIS
ELECTRODES
 A second
electrode, the dispersive
electrode, is prepared with water, gel, or
some other conductive material as
recommended by the manufacture.
 Both electrodes must be securely
attached to the skin such that uniform
skin contact and pressure is maintained
under both electrodes to minimize the
risk of burns.
IONTOPHORESIS
ELECTRODES
 The
size and shape of the electrodes
can cause a variation in current density
and affects the size of the area treated.
 Smaller electrodes have a higher
current density and should be used to
treat a specific lesion.
 Larger electrodes should be used when
the target treatment area is not welldefined.
IONTOPHORESIS
ELECTRODES
 Recommendations
for spacing between
the active and dispersive electrodes
seem to be variable.
 They should be separated by at least
the diameter of the active electrode.
 One source has recommended spacing
them at least 18 inches apart.
IONTOPHORESIS
ELECTRODES
 As
spacing between the electrodes
increases, the current density in the
superficial tissues will decrease,
perhaps minimizing the potential for
burns.
CLINICAL APPLICATIONS
FOR IONTOPHORESIS
 Clinically,
iontophoresis is most often
used in the treatment of inflammatory
musculoskeletal conditions.
 It may be used for analgesia, scar
modification, wound healing, and in
treating edema, calcium deposits, and
hyperhidrosis.
IONTOPHORESIS
Conditions Treated
Spasm:
Calcium, magnesium
Inflammation: Hydrocortisone,
salicylate dexamethosone.
Analgesia: Lidocaine, magnesium
Edema: Magnesium, mecholyl,
hyaluronidase, salicylate
Ischemia: Magnesium, mecholyl,
iodine
Fungi: Copper
IONTOPHORESIS
CHOOSING AN
ELECTROTHERAPEUTIC
DEVICE
Dr. Grant