Electrotherapy Ordinary PDF

**Electro therapy ordinary** **Framework reminder** ***Low intensity:*** less than 1000 Pulsed Uninterrupted ***Medium intensity***: 1000 until 500.000HZ Kotz IF ***High intensity:*** more than 500.000 Capacitive electrical transfer Shortwave UHV microwave ***Phototherapy:*** Laser UV...

**Electro therapy ordinary** **Framework reminder** ***Low intensity:*** less than 1000 Pulsed Uninterrupted ***Medium intensity***: 1000 until 500.000HZ Kotz IF ***High intensity:*** more than 500.000 Capacitive electrical transfer Shortwave UHV microwave ***Phototherapy:*** Laser UV IR ***Vibrotherapy:*** Shockwave Ultrasound ***Magnetotherapy*** **Electrical capacitive transfer:** 0'448 MHz Direct contact Active: hand of PT Neutral: lumbar or limb **UHF:** 434 MHz Longueur d'onde = 69cm Non-contact therapy Deeper than microwave and shortwave (6cm of increased skin temp) **Shortwave:** Wavelength: 11m Frequency: 27 MHz **Microwave:** 12,5 cm Frequency: 2450 MHz 5-10 cm from patient **Shockwave:** Max duration time: 10ns Pressure: 100MPa or 500 bar Frequency: 16-20MHz **Ultrasound:** Infrasound: less than 20 Hz Audible sound: 20-20.000 Hz Ultrasound: more than 20.000 Hz Conventional US: 1-3 MHz Low intensity pulsed US: 1,5 MHz Non-contact low frequency ultrasound: 40 KHz **SD curves:** relationship between currents amplitude and pulse durations required to produce a threshold stimulus to create an action potential in different types of nerve fibers and directly in denervated skeletal muscle fibers. AIM: maintain the functional state of the neuromuscular system or strengthen the muscles. An external electrical stimulus needs more intensity to produce the same stimulus as pulse duration decrease. Electrode placement: Anode cathode ----------- ------------------ --------------------- Monopolar Neutral (plexus) Active over MMP/NMP bipolar Proximal Distal variation Neutral over NMP Active over MMP With rectangular pulses: pulse duration: 1000ms Interval: 3seconds Decrease from 1000ms to 0ms Join the points using lines. Do the same for triangular pulses. Don't look at the intensity until there is a contraction (Watch the graphs with the different parts) Rectangular: 1-rehobase: minimum intensity needed to produce a minimum contraction (rectangular of 1000ms) normal value 1-10mA 2-MUT (muscle utilization time): normal value 1-10ms 3-faradic threshold: minimum intensity to produce a minimum contraction with rectangular of 1ms, if the curve crosses the vertical line of 1ms: BURST OF RECTANGULAR PULSES are needed if not, isolated rectangular pulses. 4-chronaxie: best pulse duration except for denervation when chronaxie will demand higher intensities. Ideal PD for muscles strengthening with rectangular pulses representing time to get the minimum energy consumption with the higher energetic efficiency. Normal values 100-700us (0,1-0,7ms) Chronaxie in denervated muscles Weakly denervated: 1-3ms Moderately:3-6ms Seriously:6-30ms Completely: more than 30 Fish gold test? Rehobasic part: from rheobase to MUT High and short=hypoexitability Low and long=hyperexcitability chronaxic part: from MUT till end of the curve (Graphic with triangular pulses) 1-galvano tetanus threshold: minimum intensity needed to produce a minimum contraction (traingular of 1000ms) Index? 2-deflexion angle: point where the graph ends its decrease to start increasing again. Ideal pulse duration using triangular and the ideal interval pulse to use with rectangular. 3-faradic threshold: minimum intensity to produce a minimum contraction with triangular pulse of 1ms. 4-accomodation part: from GTT till deflexion angle: angle formed by the curve and the horizontal line. If it tends to the horizontal line, there is an accommodation loss; if tend to 45° there is normal accommodation. vs Faradic part: from deflexion till end of the curve Accommodation in denervation depends on good metabolism: state Na+ channels and Na+/K+ pump Ionic intra)extracellular proportion Denervation: more intensity and pulse width Accommodation capacity is lost Slow response Prolonged repolarization during seconds: ISOLATED PULSES Accommodation with triangular pulses similar to rectangular pulses. **Electrical stimulation of denervated muscles:** Maintenance of muscular trophism Treatment using results of SD curves Patients without denervation: technical resources available Patient situation and proposed targets MES intensity Patient sensitivity Degrees of nerves injury: ***Neurapraxia***: lowest, nerve intact but signaling capacity damaged, temporary loss of sensory functions. Muscle weakness, compression contusion edema, last in average 6-8 weeks. *Nerves: ulnar, median, radial, brachial plexus and sciatic, peroneal nerves.* ***Axonotmesis:*** axon damaged but connective tissue intact, partial rupture that affects the axon but not the nerve, Wallerian degeneration (distal part of axon). Rate of outgrowth of regenerating nerve fibers is 1mm to 2mm per days. ***Neurotmesis:*** most serious, both axons and connective tissues damaged, impossible to recover completely. Need surgery. Reinnervation processes: Wallerian: cleaning process of neuron. Regeneration follows degeneration: Schwann cells and macrophages remove debris. Collateral: non damaged neurons increase its influencing fields including denervated fibers reestablishment of neural control of a formerly paralyzed muscle by means of proximal to distal regrowth of nerve fibers, or by sprouting from nearby intact nerve fibers. Aim of electrical stimulation: maintain trophism of muscles while waiting reinnervation Avoid muscle fibrosis due to lack of use to allow reinnervation. Steps to follow rectangular are more efficient than triangular (accommodation part) Necessary to know if burst of pulses can be used or not (RFT) Pulse duration will be adapted considering Sd curves values (no specific currents) Problems: loss of response Derivation to adjacent muscles 1. Burst of rectangular pulse with PD equal to the chronaxie ON 2-4" OFF 4-8" 2. Isolated rectangular pulses with pulse duration equal to chronaxie With interval of 4-6 seconds Chronaxie if higher than 30ms If not, use MUT. 3. (Isolated rectangular pulse with PD equal to MUT 4-6") if less than 30ms 4. Isolated triangular pulses with pulse duration equal to deflexion angle. 4-6" Application conditions: daily treatment, no more than 10 pulses per muscles and day (5 at beginning). Bipolar application over denervated muscles Treat all affected muscles Rectangular pulses application produces response of innervated and denervated fibers in the same muscle; using triangular pulse there is only response of denervated. Conclusion: MES is different in denervated or healthy muscles. In denervated the current used is chosen according to the SD curves results. **Biofeedback:** Technique to learn to control the body's function (voluntarily) by means of the information provided by the patient. Patient is connected to electrical sensors to receive information (FEEDBACK) visual or auditory signals about the body (BIO) First, we use equipment's then we can do it without. Electronic instrument to provide patient with info, education and reinforcing properties about their physiological activity in an immediate, timely and accurate manner. Learning: new functions After receiving info about his behavior and consequences. Instrument based learning based on ***operant conditioning*** techniques. Principles: reinforcement, modelling, generalization. Operant conditioning: learning process in which the like hood of a specific behavior is increased or decreased through positive or negative reinforcement each time the behavior is exhibited, so that the subject comes to associate pleasure or displeasure of the ***reinforcement*** with the behavior. Reinforcement: consequence that will strengthen an organism's future behavior whenever that behavior is preceded by a specific previous stimulus. -action which increases a behavior -acoustic/visual -positive/negative -continuous/intermittent -intermittent= fixed or variable Positive: when desirable stimulus is presented as a consequence of a behavior and the behavior increase. Negative: when an aversive stimulus is removed or prevented from happening and the rate of a behavior increase. Continuous: every time there is a correct response Intermittent: every certain response or time : fixed (very X contractions) variable (doesn't know when it is coming) Modelling: progressive reinforcement, to motivate subject (virtual reality) Generalization: when subject can perform the movement without using the equipment Signal phases: detection Amplification Filtration Processing Conversion and presentation 1. Detection: sensors Electrodes: direct signal: surface (1ground 2 actives) / implanted/ special Electrodes placement: always same place, clean area, active (1-2cm) neutral big muscles: between actives, small: next to active/bone. Transductors: indirect or physical signals: physical: temperature, electro goniometer, plethysmography, pressure probes. Indirect: skin impedance Baseline outline: clear instructions Adaptation to equipment Establish starting point 3 steps: rest/ minimum contraction/ maximum contraction Set targets: A-function's awareness B-voluntary control C-control function wo equipment 30-60 min sessions Indications: TMJ, stress, muscle transposition, nervous, atrophy, incontinence, swallow disorder, chronic pain. Contraindications: patient cognitive level. **Functional electrical stimulation:** Use of electrical stimulation to increase muscle activity in individuals who suffered from neurological conditions. Aim: improve or produce a functional movement. Patient selection: PNF should be damaged Suitable response to neuromuscular electrical stimulation Lack of limitations or joint alterations to involved joints Knee/hip arthrosis may be contraindication for FES for standing or gait. FES stops if sever spasticity and muscle retractions Functional proximal muscles should be preserved. Good skin condition for electrodes Cognitive skills Not to suffer autonomic dysreflexia Lack of sever osteoporosis or recent fractures especially in LL. FES for stranding requires strength UL, enough balance, good cardio-respiratory, good orthostatic adaptation. Contraindication: obesity morbid and not controlled hypertension. Start ASAP to improve trophism, recover neuromuscular function of partial preserved muscles 6-8 channels if possible Strength, endurance, or both. More endurance because slow fibers are the first damaged in a neurological injury. Indications in DAL: use it in DAL example: UL FES should be used with eating. Electrical parameters: BURST for tetanic contraction Progressive intensity: ramp up and down allow progressive contraction and relaxation to avoid antagonistic muscle spasms due to sudden stretch. Symmetrical balanced pulses PD: 100-500 usg\-\-\-\-\-\--1000usg More than 20Hz (20-40) tetanic contraction +50Hz (type 2 fibers) muscle fatigue (FES disadvantage) Electrodes: surface (transcutaneous): easy, acute Implanted: deep, selective, less time to put into operation, more independence but invasive, if fail surgery. Standing and gait devices: Indications: spinal cord injuries, CP, hemiplegia, CNS disorders. Use: alone or in combination (FES+orthosis=hybrid system) Disadvantages: fatigue, esthetic, time to connect. PARASTEP 1: surfaces 6 channels; 12 electrodes: 3 for each limbs 2 to quadri (stand), 2 peroneal nerves(3x flexion reflex), 2 for gluteus max and mini or paraspinal muscles. IMPLANTED: 12-34 electrodes HYBRID: surface or implanted with orthosis, Ankle-foot, Knee-ankle-foot. Advantages of FES for gait and stand Decreased muscle atrophy Circulation Cardiorespiratory training Prevent thrombosis Prevent ulcers Self esteem Disadvantages: Reduce use Strains Fatigue ANTIEQUINUS: hemiplegia, multiple sclerosis Increase gait speed, improve ankle ROM Prevent orthopedic deformities Reduce spasticity Facilitates motor learning CEFAR and ODFS: surface, pressure sensor on the heel and channel on peroneal nerve to facilitate dorsiflexion and knee/hip flexion Upper limb devices: to restore functions as grip or pincer grasp Hemiplegic and spinal cord injury Benefits: sensory motor cortex activation Improve patient functional recover HANDMASTER NESS\ hybrid Orthosis that stabilizes wrist 5 surface electrodes 2 over flexor digitalis superficialis and flexor pollicis longus, 2 over the extensor digitorum longus and extensor pollicis longus and brevis and 1 electrode over thenar FREEHAND: implanted with 8 channels: in muscles of the forearm Connected to an implanted simulator in the chest Stimulation controlled by contralateral shoulder movements. PEDAL: FES-cycling Prevent bone demineralization Reduce muscle atrophy and spasticity Improve vascular and cardiorespiratory Conclusion: great benefits for neurological patients: functional and psychological, early use improve prognosis. **Ultrasounds**: sound travelling thought a medium at frequencies above the upper limit of human audibility (20kHz) Infrasound: less than 20Hz Audible sound 20HZ-20.000 Ultrasound more than 20.000 1-3MHZ therapeutic (conventional ultrasounds) 1-10MHZ 1,5MHZ low intensity pulsed ultrasounds 40KHZ non-contact low frequency Aim is to use this mechanical acoustic energy for treating a variety of soft tissues pathologies including bone fractures and dermal wounds. Piezoelectric phenomenon: some solid materials (artificial quartz, crystals, ceramics can be electrically charged on their surfaces when they are subjected to mechanical stress. Bone and collagen have this effect. Mechanical to electrical Reverse piezoelectric effect: the application of a high-frequency alternating electrical current is applied on the surfaces of such piezoelectric materials (TRANSDUCER), a mechanical deformation follows in the form of oscillations of the material. Electrical to mechanical US frequency (depth of the lesion) : 1MHZ : deep (longer wave) 3MHZ: superficial (shorter) **M** US transmission velocity: density and elasticity **Velocity (m/s)** --------------------------------------------------------------------------- ----------- Aluminum 12890 m/s Bone 3500 m/s Cartilage 1750 m/s Muscle 1580 m/s Heart 1575 m/s Subcutaneous Fat 1215 m/s Air 343 m/s Aquostic impedance (Z) Related reflexion Z=vp (velocity x density) US reflexion Greater Z= greater reflexion Importance of conducting gel Importance between soft tissues and bones Continuous movement of the transducer avoid interference with near fields and avoid interference due to reflexion. **Interface Reflection (%) %** -------------------------------- ------------- Aluminium- Air 100 Skin-Air 99,9 Aluminium-Coupling media 60 Muscle-Bone 41-34,5 Skin-Fat 0,90 Fat-Muscle 0,80-1,08 Muscle-Blood 0,74 Us Head-Coupling media Almost zéro Refraction: non-perpendicular incidence of sonic waves Change of direction of the wave between 2 mediums US attenuation: Weaking of the US as it propagates through a medium +-----------------------+-----------------------+-----------------------+ | **Medium 1 MHz** | **3 MHz** | | +-----------------------+-----------------------+-----------------------+ | Blood | 0,028 | 0,084 | +-----------------------+-----------------------+-----------------------+ | Nervous Tissue | 0,2 | 0,6 | +-----------------------+-----------------------+-----------------------+ | Fat | 0,14 | 0,42 | +-----------------------+-----------------------+-----------------------+ | Skin | 0,62 | 1,86 | +-----------------------+-----------------------+-----------------------+ | Muscle | 0,76 | 2,28 | +-----------------------+-----------------------+-----------------------+ | Tendon | 1,12 | 3,36 | +-----------------------+-----------------------+-----------------------+ | Cartilage | 1,16 | 3,48 | +-----------------------+-----------------------+-----------------------+ | Bone | 3,22 | | | | | | | page15image3160080 | | | +-----------------------+-----------------------+-----------------------+ | Air | 2,76 | 8,28 | +-----------------------+-----------------------+-----------------------+ ABPSOPTION: Inversely proportional Penetration in mm ------------------- ----------- ----- **Medium 1 MHz** **3 MHz** Bone 2,1 Skin 11,1 4 Cartilage 6 2 Air 2,5 0,8 Tendon 6,2 2 Muscle 9 3 US depth: 3MHZ: 2cm (1-3cm) 1MHZ: 4cm (2-6cm) Effective radiating area ERA In cm2 Area of the transducer from which ultrasounds energy radiates 10% smaller that the soundhead applicator faceplate surface Beam projection ultrasonic Fresnel zone: near field, less divergent/more focused, heterogenous, therapeutic zone Fraunhofer zone: far, divergent, homogeneous BEAM nonuniformity ratio (BNR) Relation between Fresnel and Fraunhofer. Us delivered at the transducer faceplate is irregular or nonuniform of the transducer Ratio between peak intensity and the average intensity of all other spikes BNR 2-8 Determined by the intrinsic properties of the transducer (piezoelectric effect) Better piezoelectric quality, more uniform beam across its ERA, and lower BNR. Lower BNR=lower hot spots in the near field. Delivery mode Continuous; thermal effect predominant; heat and vibration, thermal energy by molecular vibration (friction) Pulsed; mechanical effect: vibration, thermal energy from movement of liquids/molecules, stable or unstable ***cavitation*** Cavitation: formation in fluids or solids of empty spaces or cavities resulting from the formation of microbubbles (hollows) Contract (compression) Expand (rarefaction) Stable cavitation unstable --------------------------------------------------- ------------------------------------------------------------- High intensity High intensity New vessels Implosion of microbubbles: high temp Bubbles begin to pulsate producing microstreaming US device do not have frequency and intensity to produce it Due to non-thermal/ mechanical effect Shockwave therapy Mechanical effects Increase blood flow Increase cell metabolism Increase collagen synthesis Increase protein synthesis Increase collagen extensibility Enhance tissue healing Treatment parameters for US. Continuous for chronic Pulsed for acute Depth 1MHZ 4cm 3MHZ 2cm Treatment surface ERA Dosimetry Duty: US pulse duration US/US period % More thermal effect closed to 100% Pulse ration On off 1:1 is the same than 50% duty cycle **US MODE** **PULSE RATIO** **DUTY CYCLE (DC)** ----------------------------------------- ----------------- --------------------- **Continuous** 1:0 100 % **Pulsed** 1:0,25 80 %  1:1 50 % 1:2 33 % 1:3 25 % 1:4 20 % 1:9 10 % 1:19 5% Indications: rheumatic disorders Contractures Tenosynovitis Capsular and ligamentous fibrosis Scar Fractures Precautions: Recent fractures Epiphyseal plates Metallic implants Acute inflammation Cavities with air Breast implants Recent radiotherapy Contraindications: Spinal cord after laminectomy Recent wound Eyes and ear Malignant area Heart area Ischemic area Thrombosis Infected lesion Pelvic, lumbar of pregnant or menstruation Keloid scar Pacemaker Gonads Plastic and cementing implants US before starting Look if boils water More than 15° angle transducer may produce reflexion Method of application Stationary technique Keep the soundhead stationary over the targeted tissue during the treatment session. (Pulsed ultrasound!!!!) Dynamic technique Continuous, slow, overlapping, circular or longitudinal movement of the soundhead over the targeted tissue during the treatment session. Semi stationary Combination between stationary and dynamic technique.\ (Pulsed ultrasound!!!!) Direct contact - Water immersion Physiotherapist with gloves. - Ceramic or plastic bucket. - Previously boiled water and at body temperature. - Irregular joints or areas with hyperalgesia. Cushion contact Previously boiled water. Irregular joints, areas cannot be submerged Phonophoresis Ultrasound plus a drug medium as the US conduction medium. US+electrical currents TRANSDUCER= CATHODE. - DYNAMIC TECHNIQUE: use VC. - US + low-frequency or medium frequency currents. - MTP, painful points, Head areas, dolorosos, dermatomes. - Areas with hyperesthesia show redness. Can be:\ -- DIAGNOSTIC -- THERAPEUTIC Electrical Currents: - --  Diadynamic. - --  Byphasic (TENS) - --  Interferential. DIAGNOSTIC: - --  (-) US; (+) ELECTRODE. - --  0,2-0,5 W/cm2. - --  TENS, IF bipolar, DF. - --  CONTINUOUS-VC. - --  More sensitivity points irradiated to the targeted area(referred pain) THERAPEUTIC: - --  (-) US; (+) ELECTRODE. - --  0,5 W /cm2 - --  PULSED or CONTINUOUS. - --  SEMISTATIONARY - --  Short time, till point sensitivity decreases. INDICATIONS - PAINFUL AREAS - CONTRACTURES. - ACUTE INFLAMMED AREAS - MYOFASCIAL TRIGGER POINTS. CONTRAINDICATIONS ELECTROTHERAPY GENERAL ULTRASOUND CONTRAINDICATIONS. Low-intensity Pulsed Ultrasound (LIPUS) Based on mechanical effects (low-intensity). Target tissue is the bone: highest US absorption coefficient. US application generates the piezoelectric effect in bone (property to convert mechanical into electrical current). 20 minutes per treatment. Noncontact low --frequency ultrasound (MIST system) Low-frequency US energy to atomize saline water and deliver it as mist to the wound to clean and debride devitalized tissues covering the wound. **Extra-corporeal shockwave therapy ESTW** Application of pressure mechanical waves outside of the body that violently impact biologic tissues for therapeutic purposes. Low to large amplitude wave formed by the sudden mechanical compression of the medium through which the wave moved. Sonic waves producing very high peak pressure in a very reduced period. Max duration time: 10ns Pressure 100MPa or 500bar Frequency 16Hz-20MHz Classification: -Focused (conversion of electrical to mechanical energy) Electrohydraulic generators Electromagnetics generators Piezoelectric generators -Radial (pneumatic principle): ballistic generators 1. Focused First ESWT produces High density energy which converges in one point Mainly used in pseudoarthrosis, lithotripsy and delayed fracture consolidation Image guiding system (echography/radiography) 2. Radial Low energy density, pneumatic system Commonly used in physiotherapy Applicator type and coupling media A coupling medium is required for mechanical energy transmission and absorption Adjustable dome membranes filled with gas, water, gel is used with focused type applicators For radial type applicators standard aqua sonic gel is used. Focused: piezoelectric similar to US 1000 crystals in a concave container High voltage applied to the crystal causes it to expand and collapse, generating the ESWT in the surrounding water medium. Radial: pneumatic system to which a handheld pistol-like applicator is attached with a cable No image guiding system because of the radial or divergent projection of the waves Applicator of 15mm Generator consist of compressed air rapidly accelerating a projectile which hits the impact surface of the applicator and cause a shock wave Different applicators: Direct beam For muscles and connectives tissues Acupuncture points Plane waves So focused (125mm) is the deeper then planar (55mm) and then radial (35mm) Waveform: compressive phase P+ Tensile phase P- RSWT present much lower P+ and P- and much longer pulse duration r-ESWT higher rise time and longer pulse duration. Energy and energy flux density: Mechanical energy in ESWT is measured in millijoules Energy flux density: amount of mechanical acoustic energy per unit area per shock EFD= E/A Millijoules per square millimeter f-ESWT more EFD: more energy over smaller area so, difference between focused and radial is that focused is deeper over a point like a target and maximum energy flux density point is at the target radial maw EFD is at the source and the target isn't reached specifically. Comparison: **Parameters** **f-ESWT** **r-ESWT** -------------------------- ------------------------------------------------ ------------------------------------- **GENERATOR** Electrohydraulic Electromagnetic Piezoelectric Ballistic **PROPAGATION** Focused (convergent) Radial (divergent) **PENETRATION DEPTH** Deep at focal point (\>5cm) Superficial on skin surface (\