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Transcript
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. 4 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. 5 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. 6 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. 21 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. 22 TREATMENT PROCESS Finally, in the changing health care environment, the clinician must consider the cost effectiveness of various treatment procedures. 23 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 24 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. 25 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. 26 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 27 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 28 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. 29 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 : 30 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 31 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. 33 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