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350 Cards in this Set
- Front
- Back
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What are the cardinal signs of inflammation?
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Pain, swelling, temperature, redness, loss of function
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The proliferative phase usually takes place during these days.
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Days 3-20
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Reparative/remodeling (maturation) days are these.
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Days 9 and on
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What is the difference between acute and chronic pain?
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How long it lasts.
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Time frame for acute pain?
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depends on the injury
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Time frame for chronic pain?
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It becomes chronic when it lasts longer than the expectations of the injury.
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Define contraindications
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Conditions under which a particular treatment should NOT be applied
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Conditions under which a particular treatment should be applied with special care or limitations is the definition of what?
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Precautions; special care may be required due to lack of feedback or mental impairment.
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Precautions are also called what?
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Relative contraindications (the risks are identified, but a decision is still made to proceed)
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What is regeneration?
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Repair process with exact same tissue that is already there (the best case scenario).
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What is repair?
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Tissue replacement with new cells.
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Factors that determine healing
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Vascular supply, extent of injury, approximation of tissue, cleanliness, nutrition, age, immune system, medication, infections
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What are two different types of healing?
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Primary intention and secondary intention
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What is inflammation?
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The body's first response to tissue damage, characterized by heat, redness, swelling, pain and often loss of function.
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The first phase of healing after tissue damage.
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Inflammatory phase, characterized by a series of vascular, cellular, and chemostatic responses.
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During what days does the inflammation phase occur?
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Days 1-6
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After trauma, how long does vasoconstriction last?
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Around 10 minutes/under an hour
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What is the initial response to an injury?
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To stop the bleeding and form a plug
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Why do we want to vasodilate after vasoconstriction?
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To clean out the area and bring the nutrients and other stuff.
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What causes the increase volume/pressure at a wound site?
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The vasodilation which leads to swelling.
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Define margination.
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A part of the process of extravasation in which leukocytes line blood vessel walls.
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What does increased blood supply/fluid to the area do?
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causes increased pressure and increased volume
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Chemical released from damaged cell walls
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Chemotactic factors
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These cells are important for immune response
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Leukocytes
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These cells are most important for wound healing
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Monocytes (later converted to macrophages)
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These attract other cells to the area
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Neutrophils
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Ingestion and digestion of bacteria and particles by a cell
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Phagocytosis
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These cells clean up all the debris.
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Phagocytes
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Define exudate.
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Cloudy wound fluid composed of protein and white blood cells or solid material from cells. This is a thicker liquid which shows up early in the inflammatory process as in blisters or sunburns.
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What is transudate?
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Thin, clear wound fluid composed promarily of serum.
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3 big chemical mediators released after tissue injury
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Prostaglandins, histamines , bradykinins (keep the inflammatory response going)
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These are everywhere in the body. Released in response to any damage to the cell membrane.
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Prostaglandins
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Second phase of the healing process is known as what?
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Proliferation phase
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What are the three phases of inflammation and healing?
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Inflammation, proliferation, and maturation phases.
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What kinds of things happen in the inflammation phase?
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Prep for wound healing; vasoconstriction, vasodilation, clot formation, phagocytosis
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What accounts for inflammation?
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Hyperemia (causes the redness and temperature change).
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What are some things that happen during the proliferation phase?
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Epithelialization, granulation, fibroplasia/ collagen production, wound contracture, neovascularization
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What are some things that happen during the maturation phase?
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Deposition, realignment of collagen, collagen synthesis/ lysis balance, collagen fiber orientation, healed injury
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What are kinins?
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Biologically active peptides that are potent inflammatory substances derived from plasma.
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What are prostaglandins?
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Substances derived from amino acids released in response to damage to the cell membrane. They mediate a range of physiological functions, such as metabolism and nerve transmission
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How do neutrophils perpetuate the inflammatory process?
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They release chemotactic agents after they disintegrate (24hrs after they show up).
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This most important cell releases many chemicals in the inflammatory phase.
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Macrophage
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Neovascularization occurs as a result of what?
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Angiogenesis without which healing cannot take place.
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What is the main difference between primary and secondary intention healing?
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In primary intention, there is minimal tissue loss. In secondary intention, wound contraction must take place first and the edges must be approximated
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Define collagen.
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The protein of the fibers of skin, tendon, bone, cartilage, and all other connective tissue.
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Define extravasation.
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Mvmt of lecukocytes from inside a vessel to the tissue outside.
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What is a modality?
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A type of treatment which will effect the patient and have an outcome (exercise, cryotherapy, ultrasound). Therapeutic exercise should be thought of in regard to highest level of function.
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When prostaglandins and histamines are together, what happens?
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Pain
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What do bradykinins do?
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They dilate peripheral blood vessels and increase capillary permeability.
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What is the purpose of epithelialization?
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To keep the fluid in and prevent leaking.
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what happens to the tissue during the reformation phase?
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It softens, and the tensile strength is significantly weakened at this point
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Describe the pain cycle.
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Muscle tension->reduced circulation-> muscle inflammation-> reduced movement-> pain-> muscle tension, etc.
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Refraction implies what?
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Bending of light
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What does absorption imply rearding light therapy?
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The ability to take in energy.
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How are the various modalities transferred to the body?
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Heat-conduction/ ultrasound-conversion/
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Inflammation that goes beyond four weeks is called what?
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Sub acute
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Name some things that cause chronic inflammation.
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A persistent injurious agent, some interference to healing, or an altered immune response.
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What is the main cell during the proliferative phase?
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Fibroblasts
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What are some considerations regarding modalities?
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Intensity, time, specific or general (hot pack size, e.g.) , depth of target
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Shorter wavelengths give what kind of penetration?
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A more superficial penetration; infrared gives the most depth.
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If you double the light distance, the instensity does what?
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Decreases by a factor of 4; it's important to monitor the results
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Superficial heat modalities should be given for about how long?
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15-20 minutes 2 to 3 times a day
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What should the temperature range be for heat modalities?
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103-110 general, 125-127 paraffin, fluido 102-123, 100 Hubbard, 92-96 Open wounds, 88 or < with m. sclerosis
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What's the rule for covering with hot packs?
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6-8 layers for hot packs.
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What should you see with superficial heat modalities?
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Superficial uniform redness (a mild erythemic response); it's necessary to peek underneath once in a while.
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The hot pack must contact the skin for what reason?
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It's a moist heat and you don't want to dampen their shirt.
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When is heat indicated?
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Musculoskeletal pain, stiffness, spasms, prep for massage and es,
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When is heat contraindicated?
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Acute and sub-acute trauma and Inflammation/Impaired circulation/Impaired sensation/DVT/Impaired cognitive function/Malignant tumors/Potential hemorrhage or edema/Ped or frail elderly
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When is the whirpool indicated?
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Wound care/Debridement/Post surgical conditions/Acute or subacute MS conditions/hydration/improve circulation/pain relief
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What are contraindications of whirlpool?
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Same as heat-Acute and sub-acute trauma and Inflammation/Impaired circulation/Impaired sensation/DVT/Impaired cognitive function/Malignant tumors/Potential hemorrhage or edema/Ped or frail elderly
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What is fluido therapy?
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An enclosed cabinet containing cellulose or silicon particles through which dry, warm air is circulated
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What are the contraindications and indications for fluido therapy?
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Same as whirlpool
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When is specific heat indicated?
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Painful conditions of hands and feet (arthritis) or joint stiffness
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Contraindications of specific heat?
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Rash/ open wounds/ scars/ skin infection/
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Indications for cryotherapy
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Edema/spasms/ musculoskeletal pain/ thermal burns/acute inflammation
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Technical term for cold therapy
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cryotherapy
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name some types of cryotherapy
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cold packs (silicone gel, frozen peas), ice massage, immersion
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How does cryotherapy treat edema?
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Reduces blood flow via vasoconstriction and increases viscosity, decreases pain
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Describe the gate control theory simply.
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Basically, the body is fooled into feeling something else
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Why does feeling something else work to reduce pain?
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Pain receptors are small, unmyelinated and slow while temperature sensory fibers are large myelinated fibers and are faster; the gate only lets the faster sensations through
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Exercise releases these natural painkillers.
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Endorphins and enkephalins
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Cryotherapy contraindications
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Impaired circulation/Impaired sensation/PVD/Prolonged application over superficial nerves(may cause neuropraxia) /Raynauds disease/Allergic reaction to cold/Lupus/
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What is Raynaud's disease?
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Circulatory disorder causing vasoconstriction of the blood vessels, usually in the fingers and toes
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How cold should the pack be?
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As cold as possible- 0 to 10 degrees
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What do we usually use in preperation for a stretch?
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heat
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What is DOMS? Causes of DOMS?
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Delayed onset muscle soreness seen usu. 24 hours after workouts/ micro tears are thought to cause
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How many layers of towels for cold packs?
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1 Layer, wet and wrung out
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Length of time for cold packs
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10-20 minutes; beyond that just cools the tissue
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What is RRICE?
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Relative rest(the affected joint or muscle), ice, compression, elevation
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Why should you use caution with compression?
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The compression doesn't allow the cold to dissipate and blisters and necrosis can result.
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Normal response to cryotherapy
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An erythemic response
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If you use heat on someone in a subacute phase of healing, what could happen?
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You could take them back to the acute phase (increased circulation, etc.)
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Topical agents help pain in what manner?
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They act as a counter-irritant and serve to distract from the pain (gate control theory).
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Length of time for ice massage
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5-10 minutes; treat to anesthesia, numbing, and achiness
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How often should you use ice or ice massage?
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15 minutes on, 45 minutes off every hour
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For how you should you use cold immersion?
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For 6-8 minutes;
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Hunting response
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Protective cycle of vasoconstriction, then vasodilation, and will occur if cold is left on for too long
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What is Vaso-coolant spray
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non-toxic non flammable liquid which produces rapid cooling via evaporation when sprayed on the skin. It is a pressurized coolant
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Contrast bath
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Alternating warm and cool immersions; produces vasoconstriction and vasodilation to produce a vascular exercise
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When should you check if patient is having a reaction to a cold pack?
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3-5 minutes
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Temperatures for contrast baths
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98 degrees warm and tap water for cool (55-65 degrees)
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Time durations for contrast treatments
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3 min warm, 1 min cool, alternate- start in warm and end in warm
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Contrast treatments indications
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Sprains, strains, stimulate peripheral circulation, trauma
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What diagnoses work well in contrast baths?
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peripheral neuropathy, RSD (Reflex Sympathetic Dystrophy), sprains, strains etc…any condition requiring stimulation of peripheral circulation.
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Ultrasound
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Deep heat modality (up to 5 cm) -high frequency acoustical energy transmitted across a crystal
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Propagation of sound
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Positive and negative pressure waves collide and produce heat
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Cavitation
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Formation and then immediate implosion of cavities in a liquid (bubbles)
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Should you use air with ultrasound?
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No-water or a conduction gel
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Ultrasound indications
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Soft tissue contractures/Pain control/Dermal ulcers/Surgical skin incisions/Tendon injuries/Reabsorb calcium deposits/Bone fractures/CTS/Phonophoresis/Plantar warts/Herpes zoster
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Ultrasound contraindications
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Malignant tumor/Pregnancy/CNS tissue/Joint cement/Plastic/Pacemaker/Thrombophlebitis/Eyes/Reproductive organs
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At what point do you reach the end of the spinal cord?
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L1..anything below is peripheral nervous system tissue.
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Ultrasound precautions
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Breast implants/epiphyseal plates/fractures/acute inflammation
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Duty cycle
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Ratio of time on and off
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Difference b/w power and intensity with ultrasound?
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Power is acoustic energy per time / intensity is power per unit area
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Cotinuous provides these kinds of effects
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Thermal and non-thermal
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20% duty cycle or below provides what?
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Only mechanical or nonthermal effects-can be used in acute phase (20% or above provides heat)
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Spatial peak vs spatial average
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Peak is center of transducer/ average is all over transducer
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Heat felt with ultrasound is produced how?
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Conversion of kinetic energy to heat after it is absorbed by the tissue.
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What might bring about periosteal pain?
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Poor ultrasound technique
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What happens to the sound energy when it enters the body?
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It's attenuated,reflected or refracted and spreads out; depth is a couple inches depending on freuency
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Ultrasound is best for treating what?
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Capsules, ligaments, musculotendinous junctions, scar tissue
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Thermal effects of ultrasound
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Decreased:pain,fluid viscosity/Increased:Metabolic rate,Blood flow,Tissue,stimulate the immune system
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Depth of penetration is inversely related to what?
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Frequency; rule of thumb is 3mhz for superficial (attenuated sooner) and 1mhz for deeper
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Non-thermal effects from ultrasound are provided by what?
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Cavitation, microstreaming, acoustic streaming
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Microstreaming
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Eddying around any small vibrating (bubbles) objects
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Acoustic streaming
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Steady circular flow of cellular fluids induced by US. Alters cellular activity by transporting material away from the US field.
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Non-thermal effects of ultrasound include these
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Increased permeability/mast cell degranulation/Histamine release/Macrophage responsiveness/Protein synthesis/Intercellular calcium
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Effective area for ultrasound
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(ERA) effective radiating area) 2-4x size of transducer
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Speed of movement for ultrasound
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Keep it moving is the rule of thumb (4cm/second or so)
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Define diathermy
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"""through heat' a technique using high frequency energy to directly heat deep tissue and produce therapeutic responses.
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Therapeutic effects of diathermy
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Increases blood flow, permeability and capillary pressure, transfer of metabolites, WBC and antibodies, removes toxins
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Diathermy has what effect on muscles regarding extensibility?
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It increases the extensibility, decreases pain and spasms
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How hot is the heat provided by diathermy?
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40-45 (104-112.7)
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With diathermy, how is energy transferred?
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Conduction and induction
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How does diathermy work?
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Two electrodes on either side so that patient becomes circuit, electrostatic field is produced
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How does inductive heating work?
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AC flows thru a coil producing a magnetic field and eddy currents-strength and density determines heat (decreases with distance)
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Contraindications for diathermy?
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Same as heat AND metal/pacemakers/ rheumatoid arthritis/around other interferential equipment/ adipose tissue
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What kind of wave (diathermy) do we use today?
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Shortwave; it's pulsed and intensity varies (40, 50 watts, etc)-frequency goes up, wavelength gets shorter and vice versa
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Why do we only use 3 ranges (diathermy)?
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So that it doesn't interfere with radio
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How do eddy currents work?
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They cause molecules to collide and the friction generates heat
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What dosage is necessary for thermal effects of diathermy?
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At least 5 watts, 21 w for definite, 48 for deep heating
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How about frequencies and times for diathermy?
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Shorter frequencies are used for non-thermal effects/ 15-30 minutes
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Give some of the mechanical effects of massage.
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results of physical forces such as compression, stretching, shearing broadening and vibration of tissues
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Does massage have physiologic effects?
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Yep. It has organic processes of the body on the cellular, tissue or organ system levels
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What about massage and reflexes?
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At timers the result of pressure or movement in one part of the body has an effect in another area.
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How about the body-mind link regarding massage?
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It has effects as a result of the interplay of body, mind and emotions in health & disease processes.
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Describe the laying on of hands effect.
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It can create a bond between the patient and the therapist.
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Slower, superficial strokes may do what? Quicker strokes?
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Relax the patient/ invigorate the patient
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What does massage do for circulation?
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through reflexive and mechanical stimuli, it increases it--Capillary dilation, stimulation of cell metabolism, decreasing toxins and increase lymphatic and venous circulation
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What does massage do for the integumentary system?
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Stimulates sensory receptors/increases superficial circulation/removes dead skin/adds moisture either artificially or through sebaceous secretions
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Define fascia
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a sheet of fibrous tissue that envelops the body beneath the skin; it also encloses muscles and groups of muscles, and separates their several layers or groups
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Massage and circulation?
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It increases it locally and enhances venous return
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Massage and physical effects?
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Facilitates removal of metabolic waste into lymphatic system and venous return
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Massage and trigger points?
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It decreases myofascial trigger points.
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What should you do with someone who has lymphedema?
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Use superficial strokes
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Does massage help the joints?
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Yes. It increases mobility and flexibility
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How does massage help the nervous system? Endocrine system?
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It stimulates the parasympathetic ns, reduces pain, increases endorphins
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Massage and immune system?
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It helps lymph flow and function via stress reduction
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Contraindications and precautions for massage
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Physically ill or nauseated/fever/skin conditions/recent injury/malignancy/bleeding/ inflammation/decreased sensation/ osteoporosis/edema/recent surgery or condition
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Should you use fragrances or scented lotions or music?
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No. It might not be something the patient likes
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What is centrifugal/ centripetal?
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Away/ toward the heart
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Once you start to work, should you remain in contact with patient?
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Yes.
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Effleurage
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A little deeper stroke that should move the skin; should go toward the heart--pressure on, stroke back
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Petrissage
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skin and muscle tissues are raised from their usual position and then squeezed, rolled or pinched in a firm, usually circular pressure.
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How long should a back massage last?
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Depends, but usually about 20 minutes
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Shingle elleurage
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Stroke in shingle fashion in layers..pressure and stroke back
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Friction massage
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Stay in one spot and then go with or across the fibers
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Variations of effleurage
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Basic sliding effleurage/shingles/bliateral tree/3 count/horizontal/knuckling
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Contraindications for laser therapy
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Eyes/can damage dna/malignancies/pregnancy/cardiac region and vagus nerve/growth plates/thyroid or glands/pretreatment with sensitizers
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Precautions for lasers
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Better to underexpose/avoid direct eye exposure/may experience syncope/if ice, before/ if heat, after
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Laser parameters for treatment
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in j/cm2; range is from 5 all the way to 48 (and higher)
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Variations of petrissage
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Basic two-handed kneading/1 handed kneading/2 handed/skin rolling/alternating finger to thumb/rolling
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When might you use friction massage?
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Areas w/ underlying scarring, adhesions, spasms and fascia
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What is the goal with friction massage?
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stretch underlying tissue, develop friction and increase circulation
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What is the deepest form of massage we use?
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Friction; variations are superficial warming (knuckles/sawing) and deep (circular/parallel/cross fiber)
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How might you control the healing with massage?
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Reinflame the area with deep massage
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What's the goal with Cyriax method?
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Mobilization of soft tissue used to treat muscle, tendon, ligaments and joint capsules. Precedes activity, across the grain, may cause numbing
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Effects of traction on vertebral bodies?
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Distraction or separation of the bodies/glides the facet joints/
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Effects of traction on spinal curves and muscles?
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Possibly straightens out curves and stretched the muscles
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Why is traction used more for cervical and lumbar spine rather than thoracic?
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Thoracic spine is less mobile and therefore has more stability
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Concentric rings of fibrous cartilage are called what?
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Annulus fibrosus
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Jelly-like substance in the middle of a spinal disc?
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Nucleus pulposus (kind of fills the center of it)
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Largest avascular, aneural structure in the body?
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The discs of the spinal cord
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How does a disc receive its nutrition?
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Pressure changes in the disc from movement and loading and unloading (think sleeping)
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Types of traction?
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Continuous/sustained/intermittent/manual/positional
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Traction effects?
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Distraction/ reduction of protusion/ stretch/ relaxation/joint mobilization/ patient immobilization
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Indications for lumbar traction
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Herniated nucleus pulposus/ impingement/ spasm/degenerative disc disease/degenerative joint disease/joint hypomobility/subacute inflammation
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Disc is aneural, how does pain develop
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From constant flexing, the bulging material forms a fissure, runs into the posterior longitudinal ligament. Eventually runs into the neural foramen
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Contraindications for lumbar traction
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structural disease /pregnancy (hypermobility from relaxin)/vascular compromise/osteoporosis/hiatal hernia/acute sprains and strains/ claustrophobia
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Precautions for lumbar traction
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Belt pressure (hernia, osteo, vascular)/claustrophobia/tmj/disoriented/ severe pain FULLY relieved/ medial disc protrusion/ displacement of annular fragment
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The lumbar treatment must begin with what parameters?
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All applications start between 25 – 50 lbs and increase 5 – 15 lbs. each treatment to desired effect
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How do you decrease compression on a nerve root or facet joint?
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Start treatment between 50 lbs. and 60% body weight
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How do you decrease muscle spasm or stretch soft tissue with lumbar traction?
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25 % of body weight
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What's the rule of thumb for friction free tables?
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Don't exceed 50% body weight
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Definition of traction
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force applied to the body to separate joint surfaces and elongate surrounding soft tissue
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What is the coefficient of friction?
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a constant which represents the frictional forces between two surfaces
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How is traction suspected to work for disc bulge/herniation (HNP)?
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The pulling motion produces a suction which decreases intradiscal pressure - pulls material of HNP back to center of disc
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Cervical traction forces start at?
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Start at 8 – 10 lbs. increase 3 – 5 lbs. to desired effect
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How much does a head weigh?
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About the same as a bowling ball (14 pounds per Michlovitz).
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With cervical traction, how do you decrease compression on a nerve root or facet joint?
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20 – 20 lbs or 7% body weight is necessary
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With cervical traction, how do you decrease muscle spasm or stretch soft tissue?
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12-15 pounds, and you shouldn't exceed 30 lbs.
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What are the treatment parameters and ratios for a disc problem with lumbar traction?
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Disc problems long hold (60+ seconds) with 3-1 ratio on:off
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Treatment hold and relax times for joint problems (traction)?
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"Joint problems 1:1 at 15 seconds
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Traction for acute symptoms?
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Acute symptoms long static hold and relax to limit movement
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Traction time and version for herniated discs?
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Saunders 6 – 8 minutes static for herniated discs
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What are the joints of the spine called?
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Facet (also spinal apophyseal or zygapophyseal joints)
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What effects can joint distraction have on the spine?
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reduces compression on joint surfaces/widens intervertebral foramina, potentially reducing pressure on articular surfaces, intraarticular structures, or the spinal nerve roots
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What about the biases of lumbar pain treatment?
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With lumbar pain, there are 2 biases of treatment (extension versus flexion biased)
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Which patients are going to go prone on the traction table?
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The ones with herniated discs, since they are extension biased
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Variables of traction include?
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Sustained and intermittent times (based on acuity of injury) / steps up/ steps down
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Would you ever use a unilateral traction force?
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Possibly, if the patient presents with unilateral symptoms you could offset the axis of traction in the direction that most reduces patient's symptoms; symmetrical central force in line with the midsagittal axis is the norm, however
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When should you decrease the force of traction (weight) during the treatment?
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if there is any peripheralization of signs or symptoms or if there is complete relief of severe pain
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With cervical traction, what should the angle of pull be??
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About 30 or 40 degrees or so
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Definition of edema?
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When excess fluid accumulates in the interstitial spaces
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How does compression help resolve edema?
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it increases extravascular hydrostatic pressure, reducing outflow from vessels and causing fluid in the interstitial space to return to vessels
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What are some causes of edema due to venous insufficiency?
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obstruction by tumor/venous valve degeneration/lack of physical activity/phlebitis
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Two types of edema are_______ and _________.
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Lymphatic and venous
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What are some causes of lymphedema?
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obstruction by tumor/degeneration of valves/lack of physical activity/removal of lymph nodes/radiation therapy damage
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What are some causes of edema due to venous insufficiency?
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obstruction by tumor/venous valve degeneration/lack of physical activity/phlebitis
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Edema caused by venous system?
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due to a pressure change in the capillary causing an out flow of proteins or a decrease in venous return
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Causes of localized edema
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Contusions-fractures-sprain and strain-burns
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Localized edema is usually present with what other signs?
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Cardinal signs of inflammation
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How do we assess edema?
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Measure/ volumetrics/palpations/temperature/ROM/ loss of function
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Give some treatments for edema
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Elevation-thermal agents-massage-nonmechanical compression-mechanical compression
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Contraindications for vaso-pneumatic pumps.
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Heart failure or p. edema/Acute or recent DVT or p. embolism/ obstruction of lymph or venous return/ severe peripheral arterial disease/hypoproteinemia/skin infections/ acute fractures/arterial revascularization
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Precautions for vaso-pneumatic pumps
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Impaired mentation or sensation/hypertension/cancer/stroke or vascular insufficiency/ superficial peripheral nerves
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Technique for VP pump requires that you first check what?
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the blood pressure
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Ratio for time on and off with vp pumps
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Usually 3:1 (like 90 seconds on and 30 seconds off)
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Treatment time and frequency for vp pumps
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Usually from the first thing in the morning until the place closes (8 hrs or more)
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The guidelines for vp pumping say to stay below what?
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The diastolic pressure; rule of thumb is 30-60mmHg for UE and 40 to 80 mmHG for LE**but with lymphedema, try to stay on the lower end
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What is TENS?
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Trans cutaneous electrical nerve stimulation
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What is MENS and FES?
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Microcurrent Electrical Neuromuscular Stimulator and Functional Electrical Stimulation
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What is NMES? EMS?
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Neuromuscular Electrical Stimulation; Electrical Muscle Stimulation
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What does the propagation of an action potential depend on?
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The type, diameter, condition, the blocks, and accommodation of a nerve.
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What is the negative electrode called?
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The cathode
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What is the positive electrode called?
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The anode
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Define refractory period.
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The period during which a stronger than normal stimulus is required to generate an action potential
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Define absolute refractory period
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The period during which no amount of stimulus will generate an action potential
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Hyperpolarization takes place where?
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The anode ; depolarization takes place at the cathode
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Define subthreshold
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An area under which you can apply a stimulus and no action potential will be generated
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If a motor response is desired, where should the stimulus be applied?
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Over a nerve (it's easier to depolarize a nerve)
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Can we get a motor response from a denervated muscle?
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Yes, with a low volt DC generator (it's always on)
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What is the Critical Fusion Frequency?
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It's the frequency at which you cannot tell the difference between the pulses (for a synchronous, tetanic contraction)
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Define amplitude
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(Intensity) measured in amps, volts millivolts (10-3), microvolts (10-6)
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Okay, what is frequency then?
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(rate)the number of pulses (PPS or Hz)-- Hertz is 1000 cycles per second
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What, then, is pulse duration?
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Also known as width, it's the time for one pulse to be delivered
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True or false: different tissues will have a different resistance.
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Oh, it's true. Bone and skin aren't that great, but muscles and nerves are pretty good at conduction.
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What is rise time?
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The time it takes to go from 0 to the peak amplitude (this might be important for muscle re-education)
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Why are the numbers regarding intensity variable?
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Different batteries, different leads, different conditions- the patient response is more important.
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Critical fusion frequency tension is __________ than a normal contraction.
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Greater
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A muscle fatigues _______ with e-stim.
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Faster
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With AC current, do we have to worry about pulse duration?
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No. With sine wave current, the machine automatically does it for you.
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What is the decay or fall time?
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The time in which the signal goes from its peak amplitude to 0 volts.
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What's the ratio of on and off called?
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The duty cycle
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We hit a critical fusion frequency at about _____ cycles per second.
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35 to 50; higher than that won't really make that much difference.
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Motor nerves are stimulated at _________ widths than what is required for sensory stimulation.
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Wider; at about 250 c/s
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Sensory nerve stimulation can be achieved at a frequency of what?
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Between 80 and 120 or 150 c/s; the pulse width is narrow because we don't want a muscle contraction
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Why would you want a different rise or fall time?
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To make a smoother, asynchronous-like contraction.
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What is significant about the on/off cycle?
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It's variable so you can set a certain number of contractions in order to reeducate muscles, e.g. (and the patient can attempt to physiologically contract)
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What is modulation? Why is it important?
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Modulation is a change in the characteristic such as intensity of pulse duration; it prevents accommodation to the synchronous contractions
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What are two theories of pain that we take advantage of?
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The gate-control theory and the endogenous opiate theory.
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What do the B,N,M stand for on the TENS unit?
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Burst, normal, and modulation (burst gives no control over frequency, just width)
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What do micro and milli mean?
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Micro is 10 to the negative 6th, milli is 10 to the negative 3rd
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The lower the amplitude, the _____ pulse width required for an action potential.
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Longer
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Why is the strength duration curve important?
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Each nerve has a strength duration curve. For example, sensory uses lower amplitude and shorter durations than motor.
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Define rheobase
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The minimum current amplitude, with an infintely long pulse duration, required to produce an action potential (threshold)
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Define chronaxie
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Minimum pulse duration that will excite a nerve fiber when a stimulus of amplitude of twice the rheobase is applied
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What effects might the charge produce?
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Depolarizing nerve fibers/the neurophysiologic excitatory effects /thermal effects/chemical effects/healing effects
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What may cause burns?
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The charge (DC has an electrode that's always positive, and one always negative so charges flow between the electrodes)
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What is charge responsible for?
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The depolarizatin of nerve or muscle fibers/neurophysiologic excitatory effects /thermal/chemical/healing effects
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How does DC current stimulate denervated muscles?
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It has a long duration and it's always 'on' (consider the strength/duration curve)
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What causes the burns, the acid or alkaline part?
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The alkaline
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How about timing modulations within a carrier frequency? (Russian stim.)
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They are bursts of AC or PC currents. Used to provide a “more comfortable or deeper stimulation"
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The electrode is the contact point between what?
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The electrical circuit and the body (must have a good contact and be in good repair)
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Describe the electrodes.
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They are usually carbon based, made of karaya gum, some are made of metal or foil
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What about the frequency of Russian stimulation?
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uses AC current with carrier frequency of 2500 cps (2500cps in bursts of 50/sec at 50% duty cycle) AKA MF burst AC (Medium Freq)
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As you increase frequency, the resistance___________?
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decreases (so it's opposite of ultrasound)
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What is the amount of current flow /unit area?
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The current density
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What's the rule of thumb for larger or smaller electrodes?
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larger electrodes tend to disperse current, smaller electrodes concentrate current
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How about placement over tissue with high impedance (skin, bone and adipose tissue) ?
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That kind of placement tends to decrease current flow
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If the electrodes are smaller, the perceived intensity will do what?
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It will increase
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What if there are unequal sized electrodes?
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The neurophysiologic response and intensity will be under the smaller electrode
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Minimum number of electrodes is what?
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2, but Increasing the number can change the current density (current spread over larger area) and intensity (to get the same effect the Intensity or Duration must be increased)
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What is a Monopolar configuration ?
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Small stimulating electrode with large dispersive
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What is a bipolar configuration?
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Bipolar – both electrodes
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What does distance influence?
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Depth of penetration
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What if the electrodes are closer together?
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The closer, the more superficial. Too close the electricity may arc between the electrodes and not reach the tissue
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The number of channels is the number of what?
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Circuits
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The greater the distance between the electrodes the _________the current density.
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Less
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The location and depth of the nerve and location of the “motor points” are critical when stimulating what?
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Innervated muscle
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The effectiveness of stimulation is best when the electrodes are what?
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Parallel to the direction of the muscle fibers
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Short pulses are primarily used to do what?
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Sensory stimulation only
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When using electrical currents to stimulate muscle con-tractions, patients should also do what?
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Perform physiological contractions
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Regarding distance of electrodes, the closer together, the more what?
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Superficial
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What happens if the electrodes are too close?
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Electricity may arc between the electrodes and not reach the tissue
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What is the rule of thumb for electrode placement?
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At least 1 electrode away from one another
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The greater the distance between the electrodes the less the what?
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The current density
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Muscle tissue is ___more conductive in the _________direction of their fibers than in the_________direction
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four times, longitudinal, transverse
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What is critical when stimulating innervated muscle?
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Locating a motor point (usually at mid muscle belly); location and depth of a nerve
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The effectiveness of stimulation is best when the electrodes are what?
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Placed parallel to the direction of the muscle fibers
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In order for the electrodes to couple to the skin they must do what?
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Be pliable/contain some sort of coupling agent(liquid,gel,water)/adhere to the area
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What are some safety concerns regarding resistance?
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Current will take the path of least resistance (use caution around cardiac area)
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Tissues with increased resistance and stimulation of high intensity and short duration may cause what?
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A burn due to ph changes
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What is the rule of thumb regarding polarity?
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Use P (positive) for pain and negative for pretty much everything else if you have a choice
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Negative must be used on what kind of muscle?
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A denervated one; + or - on an innervated muscle
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Positive polarity may be used for what kinds of things?
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Tissue healing and pain
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What polarity should be used for iontophoresis?
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Opposites attract, so use the same polarity as the ion to be driven.
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In order to increase strength, what percentage of the maximal voluntary contraction is needed?
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10% in an injured muscle, 50% in a non-injured (and 50% is painful with electrical stimulation)
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How is spasticity managed with e-stim?
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The antagonist is stimulated
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What kind of currents are used in Russian and interferential stimulation?
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Pulsatile
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What is DC used for?
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Wound healing, driving ions, stimulated denervated muscle
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What is AC current used for?
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Treats pain, stimulated innervated muscles, Russian and interferential
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What is pulsate or pulsatile current?
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electrical current that is conducted for periods less than 1 sec
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What direction is pulsatile current?
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May be unidirectional or bidirectional
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What are some possible shapes for waves/ waveforms?
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Monophasic (line), biphasic (sinusoidal), symmetrical (or not) balanced and unbalanced or even spiked
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Electrical stimulation can alter the physiologic process at what levels?
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Cellular, tissue, segmental, or systemic
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At the cellular level, estim excites what kind of nerves?
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Peripheral (nice for the gate control theory of pain)
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At the cellular level, what does estim do to the permeability?
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Changes membrane permeability (allows cells to take in more fluid)
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Sub threshold stimulation can help with what?
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Swelling, since the cells will still be affected
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How does estim help with healing?
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It modifies osteoblasts, fibroblasts, microcirculation, mitochondria /alters protein & blood-cell concentration
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How can estim affect smooth and skeletal muscle at the tissue level?
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It can make them contract (think of muscles and veins and arteries)
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What is a way to control edema with muscle stimulation?
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Cause them to contract or pump
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In what way does estim help to create analgesia?
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It causes the release of endogenous polypeptides and neurotransmitters
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How do A beta fibers help to block pain?
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stimulate the substantia gelatinosa in the spinal cord and “close the gate” to t cell transmission and pain perception
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What are the longer lasting endogenous pain killers?
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Endorphins (about 4 hour half life vs. 2 minutes for enkephalins)
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Where are endorphins/enkephalins released?
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Endorphins from the pituitary/ enkephalins from neuron terminals (receptors in spinal cord)
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What causes the release of the endogenous opiates?
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noxious stimulation of C fibers (that's what we do)
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What are pulse width settings for sensory?
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Sensory level 20 – 100mseconds (milliseconds 10-3
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What are pulse width settings for motor responses?
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Motor 100 – 600mseconds
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What are pulse width settings for pain?
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As high as possible
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At what rate might you see a twitch?
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A sub-tetanic 1 to 20
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How do you achieve a fused or tetanic contraction?
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25 to 50 for a smooth contraction; higher frequency= stronger contraction up to 80pps then no difference
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What are the frequency settings for pain in general?
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80 - 120 sensory (or 150 in some books)
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What are the settings for intensity?
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Strong, but comfortable (this is highly variable and depends on the patient)
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What are some non-specific term for ES used to increase strength and endurance?
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NMES and FES (neuro muscular estim and functional estim)
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How does Russian stim work?
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A carrier frequency serves to irritate and carries packets of 50c/s stimulation so that the stim is more comfortable and it breaks down skin resistance
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Estim contractions are more effective if the patient does what?
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Attempts to help by contracting physiologically
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True Russian stim is what in cps and what duty cycle ?
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2500cps in bursts of 50/sec at 50% duty cycle/ 2500cps delivered over 1/100th of a sec. with a 1/100th of a sec rest in between
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High volt galvanic frequency is most effective when this setting is used.
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20 -100 pps (50 more effective than lower rates) with no difference found at rates higher than 50 pps
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TENS uses what kind of waveform?
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Most TENS units have a symmetric or asymmetric biphasic wave form
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Why do TENS units produce a zero net DC potential ?
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The wave is biphasic or alternating
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What type of wave form is high volt galvanic?
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Twin wave, spiked peaks
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Uses of high volt galvanic stimulation?
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Pain, edema, muscle reeducation, trigger and motor points, etc. (+ or - is possible)
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What type of current is used for interferen tial stimulation?
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two separate interfering AC currents (four electrodes)
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Wave form for interferential stimulation?
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Sine wave (positive, negative)
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True or false: 2 currents must cross to be true interferential stimulation.
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It's true
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Uses of interfential stimulation.
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pain, edema, muscle guarding and more
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What is the current used for iontophoresis?
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Low volt DC
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What is the wave form used for iontophoresis?
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Unidirectional
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What are the treatment parameters for iontophoresis?
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Usually 40 milliamp min of treatment for any drug used (though lately clinicians have been doing more minutes)
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