PT Boards Review.docx

**[PT Boards Review]** **Cardiovascular Fitness** - Aerobic exercise -- virgous exercises that results in 50% - 80% of max oxygen consumption and 60% - 90% of max heart rate being maintained at least 15-20 minutes - Aerobic exercises = cyclic movements caused by contractions of large...

**[PT Boards Review]** **Cardiovascular Fitness** - Aerobic exercise -- virgous exercises that results in 50% - 80% of max oxygen consumption and 60% - 90% of max heart rate being maintained at least 15-20 minutes - Aerobic exercises = cyclic movements caused by contractions of large muscle masses relying on aerobic pathways - Examples = biking, jogging, swimming, jumping rope, upper body cycling, etc. - Upper body cycling is great for patients with low back pain - Cardiac output = (heart rate) x (stroke volume) - Aerobic activity increases resting heart rate and stroke volume - Healthy individual = Decrease resting heart rate and increase stroke volume Target Heart Rate Equation - 200 bpm -- age = estimated max heart rate - Estimated max heart rate -- resting heart rate = heart rate reserve - Resting heart rate is going to be lower in healthy individuals -- typically between 60---80 bpm - Heart rate reserve x heart rate range + resting heart rate = target heart rate - Heart rate range for sedentary lifestyle = 0.60 - Post-myocardial infraction patients should be doing aerobic activity at 0.60 heart rate range - Heart rate range for the average joe = 0.75 - Heart rate range for athletes = 0.90 **Terminology** Isometric, Isotonic, Isokinetic - Isometric = muscle contraction with no change in muscle length and no joint movement - Two opposing muscle contracts in opposite directions - Examples: - Patient clasps one hand into the other and pulls in opposite directions to one another - Abdominal bracing (isometric co-contraction of the internal/external oblique, rectus abdominus, transverse abdomens) - Farmer's carry, rack carry, bottom-up kettle bell rack carry, waiter's carry - Isotonic = muscle contracted by changing in length = joint movement against a constant weight - Concentric = shortening the muscle = positive - Example - Flexing the forearm producing contraction of biceps brachii (bicep curl) - Walking up the stairs - Coming up from a squat - Eccentric = elongating the muscle = negative - Example - With the forearm already flexed, extending the forearm against resistance - Walking down the stairs - Lowering down into a squat - Isokinetic = muscle changes in length while constantly changing pressure or resistance is offered to the muscle at a constant speed through full range of motion - Example - Exercising muscle using a Cybex machine - Painful arc syndrome patients do well with isokinetic exercises Open Chain vs. Closed Chain Exercises - Open chain = exercises performed typically where the hand or foot is free to move - Typically, non-weightbearing with the movement occurring at the elbow or knee joint - If there is weight applied, it is applied to the distal portion of the limb - Example: Bench press, bicep curl, leg extension, straight leg raise - Closed chain = exercises performed where the hand or food is fixed and cannot move, but the body moves. - The hand/foot remains in constant contact with the surface, usually the ground of base of a machine - These exercises are typically weight-bearing, where an exerciser uses their own body weight and/or an external weight - Example: Push-ups, handstand push-ups, pull ups, squats, lunges, wall sits **Exercise Approaches** Williams Approach - Major premise = the cause of most low back pain is acquired by walking upright in a straight position - Williams states that normal posture is with knees bent and torso slightly bent forward - All activities should be geared to [reducing lumbar lordosis] - Decrease lumbar lordosis = decrease low back pain - Williams Flexion Exercises - Abdominal crunches = isolation of rectus abdominus and obliques (strengthen core); performed in 90/90 or Goucher's position - Formerly was sit ups but changes to crunched because sit up activities the iliopsoas muscle - Pelvic Rock/Tilts = Strengthens glute max - Knee to chest stretches = stretches hamstrings McKenzie Approach - Spinal assessment and therapy based on behavior of pain and mechanical response to dynamic and static loading - Uses progressive passive loading of the lumbar spine to reduce symptoms - Extension Exercises = start prone and progressively work up to a full press-up if needed - McKenzie Exercises are used to [rehab a disc] using a [pumping action]. Buerger-Allen - Buerger-Allen = series of exercises administered to patients with vascular disease - Burger's disease, Raynaud's disease, elderly patients, bedridden patients or individuals with early-stage diabetes - With all these conditions, patients have poor circulation - Exercises are repeated 6-7 times at each sitting and done several times a day - Support legs in elevated position at 60-90° for 30-180 seconds or until you produce blanching of the extremity - Patient is instructed to actively dorsiflex and plantarflex ankle throughout procedure - Allow feet to hang over edge of bed for 2-3 minutes or as long as it takes to produce hyperemia, then add 1 minute - Total time should not exceed 5 minutes - Place legs in a horizontal position for 3-5 minutes. Plyometrics - Based on the concept of power. *[Force x speed = power]* - Plyometrics = any exercise that a muscle is contracted, eccentrically then immediately concentrically - Example - Push-up with a clap in between - Trampoline jump - Box drills (MC) Strength Training - 5 sets and 5 reps - For weightlifting, use maximum weight with 10 repetitions - To increase strength, use low reps and increased weight Proprioceptive Neuromuscular Facilitation - Advanced form of flexibility training that involves both the stretching and contracting o the muscle group being targeted - One of the most effective forms of stretching for improving flexibility and increasing range of motion - Technique: - Muscle group to be stretched is positioned so that the muscles are stretched and under tension - The individual then contracts the stretched muscle group for 5-6 seconds while a partner, or immovable object, applies sufficient resistance to inhibit movement - The contracted muscle group is then relaxed, and a controlled stretch is applied for about 20-30 seconds - Process is repeated 2-4 times. Codman's Exercise/Pendular Exercise - An exercise created to strengthen the shoulder gridle, while eliminating the use of the supraspinatus muscle - Patient will make bigger and bigger circles with their arms/shoulders - The hardest range of motion to get back is **abduction** - Finger wall-walking also falls underneath this category of exercise - Used for: Frozen shoulder, adhesive capsulitis, and rotator cuff rehabilitation. DeLorme's Exercises - A systemic approach to muscle strengthening by increasing the resistance placed on the muscle - Example: weightlifting - DeLorme's = 10 reps of 3 sets (builds muscle strength) Kegels - Kegel exercises strengthen pelvic floor muscles, which support the uterus, bladder, small intestine and rectum - Used for pregnant females and patients with urinary incontinence Jacobson's - Type of therapy that focuses on tightening and relaxing specific muscle groups in sequence - Allows the patient to become more aware of their body and physical sensations - Stress relaxation - Utilizes biofeedback through a galvanic skin temperature device Clayton's Exercises - Crawling exercises used to mobilize the spine also used to exercise muscle in patients with scoliosis - For patients with scoliosis: - 0 -- 20° scoliosis = exercise - 20 -- 40 ° scoliosis = brace - \>40° scoliosis = surgery (most likely Herrington rods) Frenkel's - Exercises that utilize ataxic motion to develop coordination - Ataxia = presence of abnormal, uncoordinated movements - Example - Wobble board or rocker board New Exercises - Deadbug = internal / external obliques and rectus abdominus - Superman = back extensors - Bridges = glutes - Planks = abdominal muscles - Slide Planks = quadratus lumborum - Side to side glide (ice skating) = gluteus medius - Wall angel = shoulder's upper thoracic spine - Knee extension toed out = vastus medialis Gait Analysis - Stance phase (anytime extremity is touching the ground) - Heel strike = anterior tibalis and posterior tibalis muscles fire - Midstance = subtalar joint is neutral, peroneal/fibular muscles fire - Toe off = gastric and soleus, foot in eversion - Swing Phase - Acceleration = quadriceps and iliopsoas fire - Mid-swing = quadriceps fire - Deceleration = hamstrings fire; foot should not "slap" - Notice that in the swing phase, the quadriceps are being utilized 2:1 compared to the hamstrings; this is why the quadriceps are a "stronger" muscle than hamstrings Supports/Braces - Orthosis = external device with controlling forces to improve body alignment, improve function, immobilized the injured area, prevent or improve a deformity, protect a joint or limb, limit or reduce pain, and/or provide proprioceptive feedback - Can be rigid or flexible - Types: - Cervical / Thoracic - Cervical halo orthosis - used for unstable spinal fracture dislocation of spine - Cervical brace - encircle the neck and supports the chin and back of head - Cervical thoracic orthosis - Lumbar / SI support - Lumbosacral orthosis - used after spinal surgery to treat low back pain from spinal stenosis - Thoracolumbosacral orthosis (Boston Brace) - applies pressure to prevent curve progression; custom molded - Hyperextension orthosis (Jewett Brace) - Used for compression fractures, osteoporosis -- prevents twisting and flexion - Charleston bending brace - Worn only at night; used for scoliosis - Milwaukee brace - Used for postural disorders like idiopathic scoliosis and Scheuermann's disease - Sacroiliac girdle/trochanteric belt - Used for SI hypermobility - Gillette Brace - Used for scoliosis - Extremity Braces - Figure eight brace (Louisiana strap) = used for inversion ankle sprains - Lennox -- Hill Brace = used for de-rotation of the knee - Cockup splint = used for carpal tunnel syndrome of the wrist Muscles To stretch a muscle = go opposite to its action To strengthen a muscle = do its action against resistance Upper Cross vs. Lower Cross Syndrome - Upper Cross syndrome - Tight upper trapezius and levator scapulae - How to fix it: have patient sit in a chair with one hand underneath their thigh (same side as tightness); doctor contralaterally flexes the neck to stretch the muscle) - Tight Pectoralis - How to fix it: have patient do doorway stretches or wall angels to stretch anterior muscles; have patient interlace their fingers behind their back and raise arms (good stretch); seated rows stretch anterior muscles (pectoralis) and strengthen posterior muscles (serratus anterior, rhomboids) - Weak deep neck flexors = LONGUS COLLI - How to fix: Have patient perform chin tucks to strengthen the longus colli - Weak lower trapezius, serratus anterior, and rhomboids - How to fix: Have the patient perform seated rows with elbows going back behind and pinching the scapula together (stretches anterior muscles and strengthens posterior muscles) - Lower Cross Syndrome - Tight thoracolumbar extensors = tight erector spinae - How to fix: Erector spinae muscles are responsible for extension, so have the patient do William's flexion exercise to stretch out the erector spinae muscles - Tight iliopsoas and rectus femoris - How to fix: Iliopsoas and rectus femoris are responsible for flexion of the hip, so have the patient perform donkey kicks (hip extension) - Weak abdominals - How to fix: To strengthen abdominal muscles, have the patient do William's flexion exercises, specifically the abdominal crunches - Weak gluteus maximus - How to fix: To strengthen the gluteus maximus muscle (action = hip extension), have the patient do William's flexion exercises, specifically the pelvic rocks/tilts **[Tight/Facilitated Upper Body Muscles]** - Pectoralis major - Stretch via wall angel, doorway stretches, or seated rows - Pectoralis minor = adduction and internal rotation - Teres major, subscapularis = internal rotation - Levator scapulae, upper trapezius - Anterior deltoid = arm flexion - Stretch via arm extension - Latissimus dorsi = extension, adduction, internal rotation - Neck Flexors (SCM, scalene, rectus capitis) - Stretch via neck extension **[Weak Upper Body Muscles]** - Rhomboids, lower trapezius, serratus anterior (upper cross syndrome) - Strengthen via seated rows - Longus Coli (upper cross syndrome) - Strengthen via seated rows - Posterior Deltoid - Strengthen via arm abduction and extension + resistance - Teres minor, infraspinatus - Strengthen via external rotation + resistance Tight/Facilitated Lower Body Muscles - Iliopsoas = hip flexion - Stretch via hip extension (donkey kicks) - Rectus Femoris = knee extension and hip flexion - Stretch via hip extension (donkey kicks) - TFL = hip abduction and maintains knee extension - Stretch via adduction of the hip across midline - Adductor group (magnus, longus, brevis) = hip adduction and internal rotation of hip - Stretch via hip abduction - Erector spinae = spinal extension - Stretch via spinal flexion - Gastrocnemius, soleus = foot plantar flexion - Stretch via foot dorsiflexion - The soleus can be isolated and stretched on its own - Anterior tibialis = foot dorsiflexion and inversion - Stretch via foot plantarflexion - For a post-inversion ankle sprain, stretch the tibias anterior rand strengthen the peroneal muscles (lateral) - Posterior tibialis = foot plantarflexion and inversion - Stretch via hip dorsiflexion - Glute Medius = hip abduction and internal rotation of hip - Stretch via hip adduction - Trendelenburg's sign is found in people with weak or paralyzed abductor muscles of the hup, specifically Glute Medius - Trendelenburg sign is said to be positive if, when standing on one leg (stance leg), the pelvis drops on the side opposite to the stance leg - Tightness of these muscles results in: - Anterior rotation of pelvis - Increased lumbar lordosis - Hips in flexion - Knee hyperextension - Genu recurvatum is a deformity in the knee joint so that the knee bends backwards (also called knee hyperextension and back knee); more common in women, especially gymnasts **[Weak Lower Body Muscles]** - Rectus abdominus and obliques = trunk flexion - Strengthen via abdominal crunches (William's approach) - Gluteus Maximus = hip extension and external rotation of hip - Strengthen via pelvis rocks/tilts, glute bridge, or quadruped hip extension with knee flexion - Glute Medius = hip abduction and internal rotation of hip - Strengthen via lateral band walk (abduction + resistance) - Hamstrings (semitendinosus, semimembranosus) = knee flexion and internal rotation of knee - Hamstrings muscles are usually weak in comparison to the quadricep muscles - Strengthen via knee flexion + resistance - Weakness of these muscles results in: - Low back pain - Knee pain - Hamstring Strains Care Management Acute = first 4 weeks - Patient presents with: (1) pain, (2) heat, (3) swelling, and (4) redness - Solution = PRICE - Protect - Rest - Ice - Compression (ace bandage or neoprene sleeve) - Elevation - McKenzie Exercises can be used during the acute phase (acute disc problems) Subacute = after 4 weeks - Patient presents with: (1) pain and (2) swelling/edema - No redness or heat = inflammation is gone - Chiropractic adjustments and passive stretching are beneficial to a patient in the subacute phase - Modality to reduce swelling/edema = contrast bath therapy - Contrast bath therapy = physical therapy treatment in which all or part of the body is immersed first in hot water, then in ice water and then the procedure of alternating hot and cold is repeated several times - Other modalities (all of these are electrical modalities that play a part in pain control) - Interferential - Deepest penetrating electrical current (can reach the facets and discs) - Good for patients experiencing "deep pain", ***intra articular pain***, or low back pain - Example: ACL/PCL pain - If a patient comes in with a knee injury and they are walking on their tip toes, you can assume this is because the patient is having intra-articular swelling - High Volt pulsed current - Goof for patients experiencing ***periarticular pain***, especially in ligaments/tendons outside of spine - Example = MCL/LCL pain - TENS - Pain control at home Chronic = after 12 weeks - No pain, swelling, heat or redness - Important to do strengthening exercises during the chronic phase of care management. ↑ Active Care = Patient Does ↓ Passive Care = Doctor Does Know about every modality 1. Action 2. Physiological effects 3. Indications 4. Contraindications 5. Penetration 6. Dosage 7. Types 8. Special tests 9. Wavelength and Frequency **[Contraindications]** +-----------------------+-----------------------+-----------------------+ | **All Modalities** | **Heat Modalities** | **Electrical | | | | Modalities** | +=======================+=======================+=======================+ | Hemorrhage (systemic) | Decreased thermal | Pacemaker patients | | | sensations | | +-----------------------+-----------------------+-----------------------+ | Infection with | Active tuberculosis | Brain | | suppuration: | | | | | Diabetes Mellitus | Eye | | - Tuberculosis | (late stages) | | | | | Heart | | - Osteomyelitis | | | | | | Carotid sinuses | | | | (baroreceptors) | | | | | | | | - Can treat from | | | | SCM posterior | +-----------------------+-----------------------+-----------------------+ | Malignancy | Low back and abdomen | Low back and abdomen | | | of pregnant patients | of pregnant patient | +-----------------------+-----------------------+-----------------------+ | | Encapsulated swelling | Decreased sensation | | | | (LVG specific -- only | | | - Herpes Simplex | electrical modality | | | | that can burn) | | | - Non-draining | | | | sinusitis | | +-----------------------+-----------------------+-----------------------+ Exception for infection = Ultraviolet (UV) - UV is both antibacterial and antifungal, so it can be used superficially - Beneficial for acne, carbuncles, bacterial infection, fungal infections, etc. **Mechanical Modalities** Massage - Physiological effects = greatest effect on the vascular system - Increase blood and lymph flow - Increase heart rate - Increases blood pressure - Breaks adhesions - Removes lactic acid - Decreases edema - Decreases congestion - Decreases nerve activity (sensation) - Indication = strains, sprains bruises, tendonitis, bursitis - Contraindications = vascular problems - Phlebitis - Thrombosis - Varicosities - Ulcerations - Local acute conditions - Types of massages: - Effleurage = stroking; begin and end of every massage by stroking toward the heart; centripetal force - Petrissage = deep kneading of muscle tissue; great for trigger points - Tapotement = percussion, hacking, cupping - Flat hand, slipping - Fist pounding - Fingertip tapping for young children - Ulnar side, hacking - Cupping for cystic fibrosis - Friction = deep rubbing - Transverse friction massage = breaks adhesions in muscles, ligaments, and joint capsule - Done across the muscle to treat scar tissue using location - Decrease chemical cross linking - Not recommended for calcific tendonitis or calcific buritis; will inflame tissue even more - Vibration = shaking; extremities only; Genie rub, G5, Thumper - Deep pressure = Nimmo acupressure Traction - Physiological effects: - Decrease intra-discal pressure - Increase IVF space - Encourage gliding of facet joints - Breaks adhesions (intermittent) - Breaks muscle spasms (intermittent) - Straightens curve (continuous) - Indications = disc syndromes, foraminal encroachment, hyperlordosis, chronic muscle spasms, fibrotic adhesions - Contraindications: - Bone weakening conditions -- osteoporosis, rickets, osteomalacia - Pregnancy - Rheumatoid arthritis - Acute muscle spasms - Fractures - Dosage: - *Cervical* = begins at [5% of body weight]; increase by 2 pounds each treatment to a [max of 50 pounds] (never exceed 50 pounds of patient tolerance) - Patient Position: - Occiput-C1 (upper cervical) = 0° netural - C2-C7 (lower cervical) = 25 - 30° of flexion - Note: it takes 10 pounds to overcome the weight of the skull; start at 10 pounds, then increase. - *Lumbar* = begins at [25% of body weig]ht; increase by 5 pounds max each treatment to a [max of 150 pounds]. - Patient Position = supine with hips and knees flexed - Relaxes muscles and flattens lumbar curve - This position is also known as [Goucher's position] or 90-90 traction **[Cold/Hot Modalities]** Cryotherapy - Application of cold modality with a temperature range between 32 - 65°F - Removes heat and reduces tissue temperature - CBAN = sensory reactions to cryotherapy - Cold - Burning - Aching - Numbness = once the patient experiences numbness, remove the cold - Psychological effects: - Primary benefit = decreasing cell metabolism - Local effect: - Vasoconstriction followed by vasodilation - Hunting-Lewis reaction is a process of alternating vasoconstriction and vasodilation - Decreased metabolic rate - Decrease capillary pressure - Edema reduction - Decreased nerve metabolism (numbness) - Anesthetic to nervous system - Systematic effects: - Increase blood pressure - Decrease blood flow - Indications: - Acute injury or inflammation - Acute, chronic, or postsurgical pain - Prevent edema formation - Prior to or in conjunction with rehabilitation exercises - Neuralgia - Contraindications: - Circulatory compromise = Raynaud's or Buerger's - Hypersensitivity to cod - Frostbite - Chilblains = painful inflammation of small blood vessels in your skin that occur in response to repeated exposure to cold - It is better to use positive pole galvanic with chilblains - High Blood Pressure - ***Dosage = 20 minutes every 2 waking hours*** - Types of cryotherapy - Ice pack = 1 towel layer for 20 minutes - Blue ice = 1 towel layer for 20 minutes - Ice immersion = 10 -20 minutes - Ice massage = 5 minutes and keep it moving - Vapo-coolant sprays = keep 14-18 inches away from patient; fluromethane (ethyl chloride) - Cryokinetics = ice massage for 5 minutes + range of motion or movement **Hot Bath** **Cold Bath** ----------------- ---------------------------------------------------- ------------------------------ **Temperature** 98 - 105° F (must be above body temperature) 55 -- 65 °F **Effects** Decrease blood pressure, vasodilation, pain relief Increase muscle tone, energy Specific Baths - Contrast = alternating hot and cold; always start with HOT; 3:1 ratio (meaning 3x more heat) - Effects = pumping of vascular system (Buerger's and Raynaud's) - Whirlpool = hot bath (98 - 105° F) for 20-30 minutes 2x per day - Effects = vasodilation, sedation - Sitz = hot bath (98 - 105° F) with only the area from the umbilicus to the thigh immersed - Effects = relief of pain from hemorrhoids, dysmenorrhea, coccyx-dyna, prostatitis, episiotomies - Paraffin = part of the body is dipped into a paraffin bath 7-10 times at a temperature of 125-130°F; wrap the body part in a hot moist towel, then have patient perform active exercises - Effects = relief of pain from chronic rheumatoid arthritis and osteoarthritis - Fluidotherapy = dry whirlpool (no fluid) - Effects = vasodilation - Hubbert Tanks = stainless steel tank filled with room temperature water; patient must place thin plastic sleeve over their extremity before putting it into the tank - Used for burn patients **[Physiotherapy Modalities]** **High Frequency** **Medium Frequency** **Low Frequency** **Ultra-Low Frequency** --------------------------- ---------------------- ------------------------- ------------------------- 100,000 HHz or greater 2,000 -- 10,000 Hz 1 -- 2,000 Hz Less than 1 Hz Heat/thermal modality Electrical modality Electrical Modality **Examples** Ultraviolet (superficial) Interferential Low-volt galvanic Microcurrent Infrared High volt pulse current Short wave diathermy SW Microwave diathermy Faradic Ultrasound (deep) TENS **[High Frequency Modalities]** - Ultraviolet - Action = thermal and photochemical - Penetration = superficial (1-2 millimeters) - Effects: - Physiological effect - Erythema = local redness of the skin caused by congestion of capillaries due to release of histamine; latent dermal erythema is observed - Tanning of the skin = due to movement of melanin (phototaxis) - Metabolic effects - Increase vitamin D synthesis, stimulates metabolism - Antibacterial - Antifungal - Indications - Skin Conditions (dirt impedes absorption) - Acne - Herpes Zosters (NOT simplex) - Fungal Infections - Tenia pedis = athlete's foot - Tenia capitis = ringworm - Chronic Ulcers - Minor burns - Slow healing wounds - Bone Conditions: - Rickets - Osteomalacia - Wavelength - Short wave (near UV) = 180 -- 270 mm - Long wave length (far UV) = 270 -- 390 mm - Logistics: - Cosine Law = optimum effect of radiation occurs when the part to be treated is at a right angle to the source of light (angulation of rays) - Most intense rays are created when the lamp is perpendicular to the body part - Inverse Square Law = intensity of radiation from any light source varies inversely with the square of the distance from the source - Example: if the distance between the lamp and the patient is 36 inches, the doctor reduces the lamp distance to 18 inches, the intensity is not 4x greater - 36 inches 18 inches (one half) - ½ x 2/1 = 2\^2 = 4 - Dosage: - UV index lamp is placed 36 inches above patient -- patch test are performed over anterior forearm - Read path test 8-24 hours after exposure - First sign of redness = MED (minimum erythemal dose) = treatment starting point - As patient tolerance increases, increase duration by 15 seconds per treatment to a maximum of 3 minutes - When maximum has been reached, decrease distance by 2 inches per treatment to a minimum of 18 inches - Maximum intensity = 3 minutes at 18 inches **Five Stages of Burns Erythema** ----------------------------------- ------------------------------ -------------------------------- **Degree** **Class** **Description** 0 SED (sub-erythemal dose) No redness 1 MED (minimum erythemal dose) Every treatment starting point 2 1^st^ Sunburn 3 2^nd^ Blistering 4 3^rd^ Swelling - Erythema = redness that usually lasts one hour - Erythema ab igne = mottled (splotchy) skin in area habitually exposed heat (infrared) radiation **Infrared** - Action = Thermal - Penetration = superficial - Physiological effects = greatest effect on the vascular system - Vasodilation - Increased circulation - Increased lymph flow - Decreased muscle spams - Decrease blood pressure - Indications - Arthritic conditions - Rheumatoid conditions - Stiff joints - Chronic backache - Contusion - Buerger's or Raynaud's - Bell's Palsy - Muscle Spasm - Subacute and chronic inflammatory conditions - Synovitis - Tenosynovitis - Sprain/Strains - Bursitis - Types of Infrareds: - Short wave infrared = 14-18 inches away from patient - Long wave infrared = direct contact with towel layers - Hydrocollator packs = moist heat - Made of a canvas filled with silica gel - Temperature = 150 -170 ° (do NOT ever go above 170°) - Must use **6 towel layers** **Shortwave and Microwave Diathermy** - Action = thermal - Penetration (both travel to muscle): - Shortwave penetrates outside in -- greatest absorption in fat - Microwave penetrates inside out -- greatest absorption in muscle belly (affinity for water) - Patient must wear wire mesh goggles - Physiological effects: - Increase temperature - Increased vasodilation - Increased respiration - Increased pulse - Increase basal metabolic rate - Increase lymph flow and glandular secretions - Increased elimination - Decreased blood pressure - Decreased nerve pain - Decrease muscle cramps and spams - Indications: - Shortwave - Bronchitis - Sinusitis - Pelvis Inflammatory disease (PID) - Arthritis, sprain - Bursitis, tenosynovitis - Radiculitis, neuritis, neuralgia - Microwave - Hip conditions - Strain - Myalgia - Myositis - Fibrositis - Additional contraindications: - Epiphyseal centers (open growth centers) - Phlebitis - Varicosities - Advance occlusive arterial disease - Edema - Brain - Metallic implants (veteran scar shrapnel) - Specifically contraindicated to microwave = sinusitis, otitis media - Settings: - CW or 400, Drum Applicator, 20 minutes, 75 intensity, chronic - 100 or 200, 65μsec., Drum applicator, 20 minutes, 75 intensity, acute **Ultrasound** - Action: - Thermal = increase heat - Pulse ultrasound can be used in acute conditions because the heat/thermal setting is removed - Mechanical = micro-massage (main use) - Chemical = increase oxidation = increased healing - Neural = mild anesthesia (radiculitis) - ***Penetration = deepest heating modality (4-8cm)*** - Penetrates to the bone/muscle interface (tendons/bursa/capsules) - Indications = pretty much everything - Joints and MSK inflammation - Subacute sprain (ligaments), strains (muscle), contusions, tendonitis, bursitis - Plantar fasciitis - Additional contraindications - Spinal cord - Plexuses and ganglia - Over epiphysis (pay attention to age) - Example: 8 y/o with an ankle sprain comes to your office, should you use ultrasound? NO. - Bony prominence (unless underwater) - Fractures - Applications - When applying ultrasound on even surfaces, use a coupling agent, such as gel or lotion - NO air or oil - When applying ultrasound on uneven surfaces, such as a bony prominence (hand, wrist, elbow, foot, ankle), submerge underwater and hold ultrasound 1 inch from the skin - Best conductor of ultrasound = water - Duration - Acute = 4 minutes (flexible) - Subacute = 6 minutes (flexible) - Chronic 10 minutes (maximum; never use ultrasound longer than 10 minutes) - Frequency = high = 0.7 -- 1.1 MHz (megacycles/second) - Intensity = therapeutic range = 0.5 -2.5 watts/sq cm - Settings - 1 MHz, 100% duty cycle, 7 minutes, thick tissue w/ heat - 3.3 MHz, 100% duty cycle, 7 minutes, thin tissue w/ heat - 1 MHz, 20% duty cycle, 7 minutes, thick tissue w/o heat - 3.3 MHz, 20% duty cycle, 7 minutes, thin tissue w/o heat - Additional information: - Piezoelectric effect (peaks at bone muscle interface) - Electrical to mechanical - Mechanical from chemical - Phonophoresis = transcutaneous delivery of ions into the body for therapeutic purposes - Performed with ultrasound - Substance may be introduced into tissues by incorporating cream/lotion/gel as a coupling medium - Drives chemicals into the skins - Examples: - Mineral ice = vitamin A and vitamin E cream - Traumeel cream = homeopathic anti-inflammatory - Goggles are needed for UV, microwave (wire mesh) and laser - Process of transmitting heat to a patient - Convection = transmission of heat by a liquid or a gas by circulation of heat particles - Whirlpool = water heats the patient - Hot tub = water heats the patients - Sauna = dry air heats the patient - Heating of a hydrocollator pack - Do not get this confused: to heat the hydrocollator pack, convection is used; when the hydrocollator pack itself heats a patient, conduction is used - Conduction = transfer of heat by a [solid] substance - Hydrocollator pack - Paraffin - Do not get this confused: when dipping the hand into and out of the paraffin bath, convection is used; when leaving the hand to dry with paraffin, conduction is used - Conversion = transfer to [electrical energy] into heat - Shortwave - Microwave - Ultrasound - Any heating modality that plugs into the wall - Radiation = transmission of heat without the intervening medium getting heated - Infrared lamp - Ultraviolet lamp - *Most radiation comes from the sun* - The sun does NOT warm the air; the sun heats up the Earth and the Earth warms the air **[Electrical Modalities]** Wave Forms - Direct current = YES POLARITY - Low volt galvanic = strongest polarity = used for polar effects - Microcurrent = used for healing effects - High volta pulsed current = "two twin peaks" = stimulate endorphins and enkephalins = pain control - Alternating Current = NO POLARITY = zero effect - Sine wave = symmetrical alternating AC wave = bidirectional/biphasic = used for muscle contraction - Faradic = asymmetrical alternative AC wave = bidirectional/biphasic = used for muscle contraction - Interferential = two medium frequencies crossing sine waves = deepest penetrating; least resistance = used for pain control, edema reduction, muscle contraction Definitions - Watts = power - Ultrasound is measured in watts/cm^3^ - Amps = current or number of electrons - Low volt galvanic (LVG) has the highest amperage - Ohms = resistance - Highest resistance = highest frequency - High frequency modalities = high skin resistance - Medium/low frequency modalities = low skin resistance - Volts = EMF-force - Joules = laser power - Rheobase = minimum stimulation to cause contraction - Chronaxie = minimum amount of time to cause a contraction at 2x rheobase - Hertz = frequency or cycles per seconds (pulses per second): frequency dictates action **[Medium Frequency Modalities]** Interferential (similar to high volt, except for penetration) - Action = electrokinetic and pain control - Penetration = deep (intra-articular) - Physiological effects: - Muscle contraction - Edema reduction - Pain control - Dosage = 20 -- 30 minutes - Enkephalins = high and fast - Settings = 70 and greater pulses per second - Endorphins = low and slow - Settings = 1 -- 10 pulse per second - Vectoring/scanning - Interferential looks similar to a four-leaf clover - Vectoring on = large treatment area - Vectoring off = small treatment area - Types - Medium frequency: - Old = 4,000 -- 10,000 Hz - New = 2,000 -- 10,000 Hz (deep penetration, very comfortable) - Russian Stimulation - Pre-modulation or bipolar settings (2 pads) - Modulation= constant changing of treating frequency equals decreased accommodation - Cycle time = 10 seconds on and 50 seconds off - Isometric contraction during 10 seconds of stimulation - Isometric performed at mid-range of motion - Low frequency - Also known as base or treating frequency - 1 -- 2,000 Hz **[Low Frequency]** Galvanic General Information - Iontophoresis = soluble ionic salts are introduced into the body tissues by electrical means - Electro-positive = bases, metals, alkaloids - Electro-negative = acids, acid radicals - Anode (positive) attract negative ions - Cathodes (negative) attract positive ions - Using repealing forces to drive ions through the skin **Negative Pole** ------------------- ------------------------------------------- Adhesions KI (Potassium iodine) or colloidal iodine Bursitis NA salicylate (aspirin) or colloidal Bruises Active pad moistened Scars NaCl Sprains KI Strains Novocain and alcohol **Positive Pole** Edema MgSO4 Fibrositis Histamine Fungus CuSO2 (Copper Kills fungus) Neuritis Histamine Low Volt Galvanic (LVG) - Action = electrochemical and electrokinetic (act of muscle contraction) - Penetration = deep - Physiological effects: - Positive pole effect (acts just like ice) - Acute pain relief - Vasoconstriction - Harden tissue - Attracts oxygen - Attracts acids - Repels hydrogen - Repels bases - Indications **Type of RD** **Faradic** **Galvanic** **Prognosis** ---------------------- ----------------- -------------------------------- ------------------------------- Partial RD Slight response Greater than faradic or normal Recovery in 2 weeks Total/Full RD No response Athetoid response (vermicular) Recovery in 3 weeks to 1 year Absolute/Complete RD No response No response No recovery - Contusions - Sprains - Myositis - Fibrositis - Intensity = 0.5 -- 1.0 milliamp/in^2^ of active electrode - Duration = 5 -- 20 minute every day - Distance = soaked pads are placed directly on the skin - Active or treating = small enough for stimulation of a particular area of muscle to be treated - Dispersive or indifferent = large enough to not have a stimulating effect (diluting effect) - Low volt galvanic (LVG) has the ability to perform iontophoresis, electrodiagnosis, and denervation - **Electrodiagnosis = to test for reaction of degeneration (RD); lower motor neuron lesion or denervation** - RD = anatomical and electrical change that occurs in muscles and nerves following an injury, which separates the muscles from its anterior horn - RD indicates the extent of damage to a lower motor neuron - Lower motor neuron = from the anterior horn cells to the myoneural junction - Maximum results are typically seen within 10 days of injury High Volt Pulsed Current (Similar to interferential, except for penetration) - Action = electrokinetic acute pain control - Electrokinetic = muscle contraction - Pain control = via the opiate system (endorphins and enkephalins) - Reduction of edema - Muscle spasms reduction - Muscle exercise - Indications: - MSK pain - Muscle spams - Acute and subacute edema conditions - Muscle atrophy - Rehabilitate weaken muscle - Dosage: - Enkephalins: high and fast - Settings = 70 or greater pulses per second - Endorphin: low and slow - Settings = 1 -- 10 per second - 0 -- 20 minutes TENS (transcutaneous electrical nerve stimulation) - Action = gait pain control and opiate pain control - Penetration = superficial - Physiological effects: - Stimulates Aβ fibers = largest, fastest, highly myelinated, no saltatory conduction - Responsible for proprioception - Stimulate Aδ (delta) fibers = smaller, slightly myelinated, no saltatory conduction - Responsible for temperature, pressure, deep and light touch, vibration and some pain - Blocks C fibers = smallest, lowest, not myelinated - Responsible for pain - Indications - All types of pain, except viscera (there are no Aβ fibers in the viscera) - TENS unit is okay to use during DELIVERY of baby, but NOT during pregnancy - Dosage: - Minutes to hors (skin irritation is common with long usage) - If the patient is experiencing gait pain, set the TENS unit to 100 pps at pw 100 - Pad Placement - Painful site - Dermatomal -- be careful with nerve root exit - L4 nerve root medial leg - L4 disc lateral leg (because the L5 nerve root) - Peripheral nerve - Trigger point - Motor point (myoneural junction) - Acupuncture point - Contralateral (developed for phantom limb pain) **[Ultra Low Frequency]** Microcurrent - Action = healing effect and pain control - Physiological effects: - Increase ATP - Increase amino acids (increased protein synthesis) - Increase healing - Decrease pain - Indication - MSK injuries -- healing - Settings - Frequency = below 1 Hz (0.5 or 0.3 Hz) - Intensity = below patient perception - Tissue healing 200 -- 800 microamps **[Cold Laser]** Cold Laser (similar to microcurrent) - Action = decrease inflammation and decrease pain - Physiological effect = increase blood supple to aid in healing - Additional contraindications: - Neoplasms - Over the eyes - Thyroid disorders - Intensity settings: - Below patient perception = microcurrent - Patient perception = pain control - Patient twitch = endorphins - Patient comfort or tolerance = muscle contraction - Classes: - Class I = printers - Class II = grocery marker - Class III = used for momentary exposures; likely to burn (3b); increase ATP - Class IV = responsible for burning - Class IV = surgical laser **[Misc.]** - Contraindication to inversion therapy: - Hypertension - Glaucoma - Fracture - Fast twitch fibers - White due to lack of Myoglobin - Explosive power - Anaerobic glycolysis - More mitochondria - Marathon runner - Lateral epicondylitis = affects the extensor carpi radialis brevis - Also known as tennis elbow - Medial epicondylitis = affects the flexor carpi radialis and pronator teres - Also known as golfer's elbow - Chondromalacia patella = weaking of the vastus medialis obliquus = lateral patellar tracking = knee popping - Modified Thomas Test = iliopsoas - Scheuermann's disease = extreme kyphosis = have patient perform extension exercise **Deep Tendon Reflexes** **Spinal Nerve Root Involved** -------------------------- -------------------------------- Biceps C5, C6 Brachioradialis C6 Triceps C7 Patellar L4 Achilles S1