Week 3 Summary TI PDF

3.1 intro to TES basics of electrical current charge: obtained by a net charge in concentration of the number of electrons within a system net loss of electrons = + charge collective gain = - charge ion: a molecule that has gained or lost an electron 4 fundamental properties of an electrical charge 1. 2 types of charge: + & - 2. like charges repel, opposites attract 3. charge is neither created or destroyed 4. charge can be transferred from one object to another to another current: quantity or amount of ion or electrons flowing at a given time international unit of current: amp system of opposite charges electrons move from a negative charged pole ( higher concentration of electrons) to a positively charged system (pole w fewer electrons) cathode vs anode cathode: - charge pole anode: + charged pole electric field: force that results by separation of charges, mates whether its attraction or repulsion, creates a system of potential energy voltage accumulation of electrons at 1 point in circuit a. creates deficit at another point b. potential energy voltage is a resulting electro-motive force created by difference in potential 2 diff charges on a battery create a concentration gradient potential energy created in an electrical current is described by a force of attraction or repulsion voltage represents the driving force that changes the relative concentration of electrons in a closed system flow of electrons from the negative pole( excess of electrons) >> pos pole (deficiency of electrons) >>create a current (measured as voltage) conductor vs insulators conductor: material that allows free mvmnt of electrons insulator: material that disrupts free mvmnt of electrons ex: rubber skin is a conductor of a current and fat is an insulator, skin will mediate the flow of current while fat will disrupt it aspects of electrical wave forms; negative and positive look at her! used to determine the physiological impact of therapeutic electrical stimulation. 1. amplitude 2. rise time 3. decay time 4. frequency 5. duration sinusoidal waveform is an AC current types two prim types of electrical current (flow or time): 1. alternating current (AC): uninterrupted bidirectional flow of ions that changes direction at least 1 time per second 2. direct current (DC): continuous unidirectional flow of ions or electrons for at least 1 sec -modes of neuromuscular stimulators a. FES: fxnal electrical stimulation b. NMES: neuromuscular stimulation c. TENS: transcutaneous electrical neurological stimulation d. EMS: electro muscular stimulation -microcurrent electrical nerve stimulation- MENS MENS differs from NMES bc it uses a much smaller current, so it will not activate sensory or motor nerves numerous preprogrammed parameters that offer varying physiological benefits take-aways 1. a current is the quantity or amount of ion or electrons flowing at a given time—the international unit of current is amperage. 2. voltage is a resulting electro-motive force created by differences in potential. 3. a conductor is a material that allows the free movement of electrons, while an insulator disrupts the free movement of electrons. 4. the aspects of electrical waveforms are used to determine the physiological impact of therapeutic electrical stimulation. 5. direct current is the continuous unidirectional flow of ions or electrons for at least 1 second. 6. alternating current is the uninterrupted bidirectional flow of ions that changes polarity at least one time per second. 3.2 aspects of an electrical wave an uninterrupted AC vs DC bidirectional flow continuous unidirectional flow of ions or electrons for at least one second. not synonymous w a positive current is either positive or negative ions electrons must change directions at least 1 time per second. if current doesnt change direction at least 1 time per sec.. current is aspects 1. 2. rise time 3. decay time 4. frequency 5. considered amplitude direct current. spoke about phases, cycles and poles for 4 (no phases) & 5 duration amplitude amplitude: strength of a current at any 1 point in time :magnitude of a current or voltage with respect to the isoelectric line amplitude will also represent the magnitude of both positive and negative currents. rise and decay rate of rise: refers to how quickly phase reaches its max amplitude rate of decay: refers to how quickly the phase goes from peak amplitude to 0V (isoelectric baseline) both rates are associated w ramp time of TES :time it takes a current to reach max intensity during each on cycle forms of rise and decay square and rectangle waveform shapes depict an instantaneous rise, a maintained peak amplitude, followed by an instantaneous decay triangular shape depicts a rapid, but not instantaneous rise & immediate rapid decay after reaching its peak amplitude phase and cycle duration phase; AC or DC position of waveform at a fraction of time period refers to the flow of a current in one direction at a set period of time can be seen in DC and AC duration of the phase speaks to the time it takes for the waveform to complete ONE direction of current flow, (+ or -) duration is expressed in seconds, milliseconds, or microseconds cycle of an A/C current above is comprised of one negative phase and one positive phase cycle: AC one complete repetition of a sine wave measured in time from the beginning point on the baseline to its terminating point pulse current is used for promoting muscle strengthening & activity bc PC is a series of pulses, muscle fibers can be stimulated frequently called tetanic contraction aka sustained muscle contraction unlike D/C currents, the cycle pattern of TES allows for muscles to depolarize and repolarize before depolarizing again. modification of AC and DC currents in the therapeutic use of estem is periodic cessation of electron flow for a period of time before a following electrical event. uni or bi-directional flow is called pulsatile current. most AC or DC currents are not appropriate for therapeutic application- given pt tolerance and potential for tissue damage important application, the modif of either a A/C or D/C waveform by intermittent determination of 1. phase duration 2. cycle duration 3. peak amplitude 4. peak to peak amplitude (bw + & -) 5. interpulse interval 6. intrapulse interval electron flow followed by another electrical event means depending on the waveform, the term pulse so sorry didnt know how to make this shorter is used instead of either a cycle or phase. pulse can be used interchangeably with phase (sometimes) types of pulsed currents 1. 2. biphasic monophasic deviation from an isoelectric line of an electrical current in one direction for a short period of time. deviates from the isoelectric line first in one direction, so positive, then negative, up: positive down: negative 3. burst if a pulse is one second or longer duration, it's considered to be interrupted D/C current, not a pulsed current. monophasic pulses are repeated with an interpulse interval instant rise maintained max amplitude instant decay biphasic repeated with an interpulse interval has two separate phases of negative and positive electron flow. pulses are not interchangeable w the term cycle. burst currents when 2 or more consecutive pulses are separated from the next series of consecutive electrical bursts primary method of delivering therapeutic electrical stimulation. frequency parameters use: pulse per second (PPS) frequency 1. non-pulsed currents: # of cycles/sec (CPS) 2. pulse current: # of pulses/sec (PPS) how many times one cycle of a waveform is repeated per second, it is measured by the unit hertz, or Hz take-aways - direct current: continuous unidirectional flow of ions, or electrons, for at least one second. -Alternating current : uninterrupted bidirectional flow of ions that changes polarity at least one time per second. -The depiction of an alternating current is a wave superimposed over a horizontal line. horizontal line depicts an isoelectric baseline, which means there's no charge. -Anytime the waveform deviates upward from the electrical line, this indicates a current flow in the positive direction. -When the waveform moves below the line, here, this is when the current flow is negative. -The parameters of a waveform include the amplitude, rise time, decay time, frequency, and duration. -An important modification of A/C and D/C currents in the therapeutic use of electrical stimulation is the periodic cessation of electron flow for a period of time before a following electrical event occurs. -This is called a pulsed current, and it is the most common form of therapeutic electrical stimulation used. 3.3 TES treatment Indications transcutaneous electrical neuromuscular stimulation- TENS has not been found to be more or less effective in treating different types of pain, such as acute or chronic. research assessing effects of TENS: using handheld units underlying mechanism for pain mngmnt thru TENS is via TES indications 1. sensory nerve stimulation 2. motor nerve stimulation 3. tissue healing 4. edema management nociceptive modulation TENS does not manage pain, but the central processing of nociception sensory nerve stimulation pain managment a. gate control theory b. descending inhibition, central mechanisms 2 prim category for TENS 1. high frequency (conventional tens): sitmulates large A beta fibers promote local peripheral nerve or dorsal horn nociceptive modulation thru gate control theory mechanisms pts perspective: high frequency tens is better tolerated and can be used during active mvmnt 2. low frequency (acupuncture tens): used to stimulate muscle and produce central mechanisms for nociceptive modulation due to higher intensity levels and activation of muscles, is not recommended during mvmnt offers several hours of pain relief -due to acting on descending methods of nociception modulation or central mechanisms motor nerve stimulation 1. muscle strengthening a. increase force of muscle contraction motor nerve which has a lower b. overload threshold for activation than the principles of tissue overload: actual muscle states that the progressive increase in wt, frequency or # of reps of an exercise will promote tissue adaptation 2. muscle re-education a. contraction often inhibited b. not to increase force of muscle contraction using TES on innervated muscles, reflect activation of -when used in conjunction with exercise or alone later stages of healing little to no difference bw TES and exercise for strength higher the strength of TES the greater -goal is not to increase force of muscle contraction amount of strength gained. -intensity of currents match demands of specific fxnal tasks (no overload priniciple) -only applies to tissue that is innervated using TES for de-innervated tissue: higher intensity of current needed to directly stimulate involved muscle increase force & muscle contraction..only if increasing intensity of TES during tx acuity & tx found to be more beneficial in initial periods of rehab when voluntary exercise may be difficult TES for strength training: special attention needed for location as well as strength of current. c. re-establish dormant motor pathways : incorporated in POC of pts w inabilities to intentionally activate their muscles could be from stroke, head trauma or SCI 2 prim modes of TES 1. NMES 2. FES tissue healing & edema control 1. preventing and reducing inflammation a. acute management b. chronic management 2. tissue healing a lot of research for tissue healing greatest effects of healing found in pressure ulcers (especially in later stages of progression) -use of selective polarity to promote specific biological effects tied to normal stages of healing ex: neutrophils, macrophages and lymphocytes are charged and pulled toward oppposite charge endothelial cells orient themselves in line w fields created by electrical stimulation, and fibronectin, cyclic AMP, and protein kinase activities increase in response to the electrical stimulation field. current is applied directly on to wound and/or area around it w consideration to polarity thought that positive charges are used to enhance early stages of healing, while negative charges are used to promote healing in later proliferations of healing. high volt pulse currents are most commonly used and supported current for tissue healing contraindications and precautions contraindications 1. pacemaker: application to trunk or heart regions: defibrillators, and/or other stimulators such as phrenic nerve and/or urinary bladder stimulator 2. carotid bodies: any placement of electrodes at the anterior lateral aspect of the neck 3. peripheral vascular disease: including arterial and venous thrombosis, 4. pregnancy: especially suffering from miscarriages 5. phrenic nerve, eyes or gonads: direct application 6. hemorrhages Precautions 1. cardiac dysfunction: including but not limited to hypertension and tachycardia. 2. impaired cognition, communication or sensation 3. neoplasms 4. neuropathy 5. compromised skin: distinction here on the compromised skin is for tissues that are vulnerable to hemorrhaging or those with a hematoma 7. active osteomyelitis Take-Aways 1. TES has been found to offer therapeutic benefit for 3 reasons a. Sensory Nerve Stimulation for pain management. b. Motor Nerve Stimulation to promote movement and to increase muscle force generation. c. Tissue Healing and edema management 2. As with any treatment modality, there are precautions and indications for their use. Know these! 3.4 Therapeutic Eléctrical Stimulation (TES) Treatment Parameters affect muscle contraction Modes of TES 1. Neuromuscular stimulators - neuromuscular electrical stimulation (NMES) - functional electrical stimulation (FES) - transcutaneous electrical neuromuscular stimulation (TENS) 2. Microcurrent electrical nerve stimulation (MENS) does NOT affect muscle contraction TES treatment parameters therapeutic electrical stimulation maintain/increase muscle size & overall fxn good for OP, acute rehab for denervated muscle NMES/EMS interchangeable promote improved efficiency in muscle contraction/activation for loss of proprioception weakness coordinated muscle contraction following an injury increase overall size/fxn of muscle IF NOT paralyzed can be coordinated w/ or w/ active mvmt textbook: EMS stimulation of denervated muscle w/ no references others: NMES w/ parameter modification can be used for both innervated/denervated Pattern of NMES predictable/repeating pattern FES promote mvmt assist in ambulating indirectly promote CV conditioning slow bone demineralization following neuro trauma Settings that use FES neuro rehab - electrical stim mediated by external sensor that turns on current when requirements met - ex: heel sensor, activates when pt puts weight on it, promotes gastroc activation during ambulatory training TENS (transcutaneous electrical neural stimulation) most common activate sensory n to manage pain DOES NOT activate muscles lower intensities than NMES/EMS Microcurrent electrical stimulation VERY low current intensity to promote physiological response in tissue DOES NOT stimulate motor/sensory n - doesn’t manage pain or rehab muscles mediates tissue healing Waveforms & Polarity Monophasic Biphasic Alternating Current Direct Current All characterized by ability to affect biological tissue by waveform’s polarity or average charge cumulative charge of each phase in treatment session determining waveform’s average charge charge determines magnitude of physiological effect when stimulation to active tissue DC; positive polarity of 5 milliamps same polar zone at same amplitude for EVERY phase (1) average charge = +5 AC: biphasic w/ equal amplitudes in phase duration of +5 and -5 average charge = 0 (cancel each other out) All the ones that don’t end in 0 net charge direct current monophasic pulsed asymmetrical unbalanced biphasic current symmetrical has average charge of 0 asymmetrical not 0 Monophasic waveforms interphase/interpulse intervals long enough to control negative side effects to net charges while being therapeutic - interpulse phase: like rest periods b/w set of exercises healing edema control muscle contraction common use: high voltage current Direct current DOES NOT have interphase/pulse intervals charge builds on tissue HARM potential: discomfort, pain, tissue damage DC precaution form of treatment using electrical current to - aka medical galvanism stimulates tissues that have high thresholds for activation provoke muscle activation - ex: denervated muscles DOES NOT stim nerves stimulates muscle membranes directly medical galvanism: any some more sensitive to ion mvmt b/w electrodes & skin causing tissue breakdown more popular in high charge currents Preferred modalities for pain & muscle contraction biphasic & alt currents Asymmetrical biphasic current: dont have identical durations/amps average charge = 0 bc both phases equal in amp and duration 3.5 TES Treatment Parameters 2 general rule: higher freq = greater Frequency: how many times one cycle of waveform repeated per second strength of current Impulse current = # of times 1 impulse of waveform repeated per second Muscle contractions below 85 pulses per second = most effective activating muscle higher freq - muscle fatigue - greater muscle activation nothing over 100 bc diminishing return/poor subj tolerance strength of current Pain control: freq depends on theoretical physiological effects Lower = 1-10 pts, lower waveform amps, shorter pulse duration freq intensity pulse duration - pain management - prevents muscle contraction Higher = 80-150 pps - gate control - central biasing/descending models of nociceptive inhibition - reduce pain after administration of therapeutic electrical stim Intensity = max amp of wave clinically = pt tolerance - want it the highest they can handle sub max contraction for pain management increased to promote muscle contraction during NMES EMS deeper penetration of electrical currents increased effect of n and muscle depolarization leading to noxious stim/tetany in muscle = pt uncomfy Duty Cycle (on time/tot treatment time x 100%) on = pulses/burst off = nothing on & off times of current: normally 2-5 seconds per interval therapeutic effect/muscle reeducation = 1:5 10 sec on 50 sec off for 60 seconds = prevents muscle fatigue (can do smaller ratio if pt can handle) 1:1 - edema - calm muscle spasms Ramp: increase/decrease in intensity of a series of pulses Ramp up = intensity increased Ramp down = intensity decreased Rise/Fall = time it takes for intensity in single phase to reach max amp and then from max reach isoelectric line Clinical app long ramp - less current for pt shorter ramp up/downtime - muscle contraction ramp up 1-4 sec - muscle contraction, reaching appropriate intensity for muscle activity faster ramp time 4-8 sec - comfort, calm spastic muscles FES - max intensity immediately for fxnal mvmt NO RAMP TIME Pulse Duration longer pulse = more tissue stim by current & motor neurons gait control mechanisms for nociception = 50-125 microseconds denervated muscles, depolarization of muscle membrane = long pulse duration - 200-600 microseconds or as long as 10 milliseconds - can also be helpful for descending inhibition mechanisms for nociception - normally for noxious stim Precaution always watch pt w/ high pulse duration can produce motor response can perceive as painful stim help me.. feeling like diesel rn Why increase pulse duration LOL increase amp for longer time stimulate structures w/ higher threshold all depends on pt discomfort Strength Duration Curve combos of stim amp & duration that elicit motor response w/ muscle activation denervated muscle more amps/duration to active motor points in healthy/partially generated muscles all depends on anatomy 10-20 min avoid fatigue (normally EMS) aim to improve muscle strength NOT neuromuscular reeducation 45-60 min 5x week depends on injury/ device 20-30 min 30 min multiple times a day summary primary therpeautic electrical stim - neuromuscular stim - microcurrent electrical n. stim direct alt impulses all used in TES each parameter has different physiological effect watch pt tolerance, fxnal goals, safety 3.6 TES Settings fast acting pain relief gate control theories of pain motor nerve stimulation 30-45 min no muscle activation clears inflammation, increase of venous return + = early, - = later 3.7. Therapeutic Electrical Stimulation NAMED CURRENTS Objectives: Know the named currents Diﬀerent uses Understand basic electro biophysical eﬀects for each named current TES named current definition Named currents are variations of basic currents, (direct, alternating, pulse) Interferential: Used for pain control and muscle stimulation, May be more eﬀective in producing force production in muscles vs Russian. A/C easily penetrate skin. Summative currents from this travel deep into tissue Currents travel past superficial aﬀerent nerves which makes it more tolerable Stimulates large area. Parameters interaction of two currents. The sum of the amplitudes creating constructive interference. This is called beat frequency, clover leaf electrical field Typically adminstered with 4 electrodes. Placed in a way that curernts intersect with eachother. QUADRIPOLAR IFC. Russian: Alternating Current, muscle stimulation. Delivered in BURSTS HIGH frequencies. 1000-2500 hz Waveforms= Polyphasic or Biphasic Less resistance in skin= more current to reach deeper nerves HIGH Intensity to stimulate the larger FAST TWITCH motor units. Duration needs to be short for tolerable experience. Parameters 1000hz 2-5ms for best muscle activation Microcurrent: Mimics body’s electrical field to encourage healing Use for bone fractures and tendon ligament healing Intensity is less than 1mil amp, variety of waveforms (ac dc mono and biphasic) Low frequency 0.3-50hz Pulse duration 1-500ms relatively long HIGH Volt Current: stimulate both sensory and motor nerves pain management, soft tissue healing, and muscle stimulation MOST indicative for tissue repair and healing uncomfortable- short duration and high intensity DONT USE to strengthen muscle Parameters: Monophasic waveform Large Intensity Instantaneous rise/rapid decrease Duration 40-100 ms and freq 60-125pulses/sec Great penetration Short durations so its more bearable 3.8 Instrumentation Electrodes What is an electrode? Proper maintenance of electrodes Application Precautions and contraindications for electrical stimulation Electrodes- device that relays the current between electrical stimulator and the patient 2 types- TRANSCUTANEOUS, INDWELLING goes into the skil : Care for electrodes have certain amount of uses, record number of times used & only Disposable electrodes need gels to be applied patients need to have their own electrodes. i SanitationPinlead needs to be inspected - tearing ? Pitting? -most common place for burns Application patient allergies? to adhesives shave hair It can get "hot spot" evaluate treated skin water) soap burns wash skin choose right size - smaller the size the greater the current density what are you treating? Will currents travel to adjacent muscle? ask patient during treatment of perceived sensation always !! - - - high intensity If using Placement of Electrodes ad! 3 methods for placement get bigger p dermatomal, sclerotomal, myotomal Dermatomal- placed over sensory nerves Myotomal- over motor nerves or points - normally proximal third for appropriate motor response. Placement distance needs to be appropriate motor points are "the locations where the greatest motor response is found for a given Stimulus" Further but not too far apart : deeper current Contraindications pacemaker, carotid bodies, peripheral vascular disease, pregnancy, placement on phrenic nerve eyes or gonads, hemorrhages, active osteomyelitis Precautions cardiac dysfunction, impaired cognition, neoplasms, neuropathy, compromised skin ↑ we HAVE to know these 3.9 SHOCKWAVE THERAPY Obj What is Extracorporeal Shockwave Therapy (ESWT) 2 types Parameters Application, Precautions, contraindications ESWT is the transcutaneous use of high energy acoustic waves for a biophysical eﬀect. NOT ultrasound. ESWT is cold tech. Much lower freq, and higher intensity Ultrasound energy is lost in the form of heat Shockwaves is cold tech, so penetrates deeper because of no loss of energy Used to breakdown tissue to promote healing and repair. MACRO aﬀect- promotes inflammatory aﬀect in tissue Microjets promote increased permeability in the same tissue 2 types FOCUS, RADIAL Parameters High peak amplitudes, Short Ramp Times freq 1-4hz. 1000-4000 shock wave pulses. Measured in joules per area (mJ/mm^2) This means 4000 to 16000 pulses/sec Therapeutic Eﬀects from ESWT Increased collagen synthesis cellular proliferation and wound healing pain reduction neovascularization decrease in soft tissue calcifications decrease in inflammation Found to be MOST USEFUL for chronic musculoskeletal conditions for tissue healing like achille tendinopathis, knee osteoarthritis, chronic plantarfaciitis Radial vs Focused Focused- inside applicator or wand , focused be lens , deeper tissues. Radial- means of compressed air through a tube, More superficial, for superficial muscle, and myofascial trigger point treatments Contraindications pacemakers prolonged blood clotting children pregnant acute injuries 3.10 Diathermy Diathermy - Definition - Use of electromagnetic waves from radio frequency or microwave frequency ranges of electromagnetic spectrum - Electromagnetic waves are defined as being an electrical field that couples w/ a magnetic field - 7 types of waves ordered by energy - From high to low - Gamma, X-Rays, Ultraviolet radiation, visible light, Infrared radiation, microwaves, radio waves - Delivered in 2 forms - Shortwave Diathermy radiowave - Microwave Diathermy - Principles of SWD - Continuously delivered through pulses or bursts of energy - Primary benefit is its ability to produce heat - Allows deeper penetration that other heat modalities - As radio or micro waves pass through tissue, energy is gradually converted to heat - Increases tissue temperature - Speed of tissue change depends on parameters of waveform & distance away from target tissue - Intensity, pulsed, continuous - Radio & micro waves frequencies encounter minimal reflection at tissue interface & on bone - Shortwave Diathermy - Capacitive T - Use condenser plates to transfer oscillations of electric field b/w plates - Target tissue placed b/w condenser plates, acts as capacitor to store electrical charge - More prone to cause burns in patients if modality is not used properly - Graded response to electrical fields, depends on how much energy is absorbed by treated tissue - Adipose tissue has naturally higher level of resistance to electrical waves - Does not heat tissue as deep as inductive - Inductive - Contain coils that create a magnetic field - Coils confined to flexible cables or within rigid drum - Field projects forward to generate circular electric field within target tissue - More commonly used in clinical settings - Can selectively heat muscles, safer application WH > Physiological Eﬀects - Will not depolarize nerves or muscles - Pulse rate is 36 nanoseconds - Goal is to increase temperature of body tissues - Thermal Eﬀect are dependent - Continues vs. Pulsed - Proximity of emitter - Duration of treatment Indications - Metabolic Reactions - Vascular Eﬀects - Neuromuscular Eﬀects - Connective Tissue Eﬀects - Diathermy has shown to promote soft tissue & bone healing - Studies show benefits in treating peripheral neuropathies, knee OA, chronic pelvic pain, lateral epicondylitis - Other studies show no benefits in subacromial pain, chronic neck pain - Considered to be one of most eﬀective modalities to heat tissue - Best used for heating large joints/muscles - Tissue temperatures should be elevated to 104-113 F · & I need to dissect this ToO Application - Important clinical considerations need to be made before using Precautions & Contraindications can we make an index card for these Take Aways - Diathermy refers to use of electromagnetic waves from radio or micro waves frequency ranges of electromagnetic spectrum - Diathermy is one of the most eﬀective modalities to therapeutically heat tissue - Know the precautions & contraindications of this modality 3.11 Laser Therapy Definiton - An acronym for “light amplification by stimulated emission of radiation” - Use of laser to promote a positive photo-biostimulatory eﬀect in tissue - Laser therapy is variable medicine - Low-Level Laser or Cold Laser - Low intensity non thermal lasers, for healing wounds & painful inflamed neuromuscular conditions Principles - Light produced in stimulated emission is a single wavelength - Absorption will vary, depends on wavelength of the light - Greater the energy, greater energy absorbed - Theorized eﬀect of laser - Energy from amplified light is transferred to cells of soft tissue - Lasers in therapy are classified as 3b lasers - Eye protection is needed from both clinician & patient Physiological Eﬀects - Tissue Repair Quantity of light absorbed is tied to therapeutic eﬀects of laser - Light absorbed by cells can result in alteration, facilitation, or inhibition of cell-mediated chemical reactions - Within cell membranes, photosensitive molecules correspond to specific wavelengths of light - Infrared, stimulates mitochondrial cytochromes - Visible, stimulates myoglobin & hemoglobin - Infrared light found to increase ATP synthesis, promotes cellular repair & reproduction - Also increases production of RNA, which codes for pro-collagen production - Promotes neuron growth in animal studies - Pain & Inflammation - Associated w/ increased levels of endogenous opiates, increased vasodilation - Also decreased inflammatory mediators, decreased depolarization of C fibers, decreased motor & sensory nerve connectivity Indications - Studies on safety & eﬀectiveness of laser therapy - Relative benefits to the use of low-level laser therapy in neck pain, jaw pain, hyper mobility, fibromyalgia, plantar fasciitis - Considered to adjuvant treatment - Does not oﬀer same benefits of more eﬀective interventions, like exercise & chronic spine pain - Found to oﬀer a positive ADD-ON eﬀect - Superior to placebo eﬀects when used in isolation - Not a stand alone treatment in management of pain syndromes, info, or promotion of wound healing - Oﬀers pain management benefits in conditions of pain syndromes at infrared wavelength of intensity - Lower dosages seem to have better outcomes - TMJD: temporal mandibular jxn dysfxn - Most heavily reported use of infrared lower-level laser therapy - Consistent therapeutic benefits in management of pain - Wound Healing - Outcomes varied, mechanisms have not bee verified - Recently shown some positive add ons to traditional care - Seems to help metabolism of human skin cells w/o aﬀecting neural biofilm bacteria or fungi - Therapy should be predicated to an individuals response to specific modality Application - Most laser devices require entering specific dosage - Laser delivering parameters need to be set - Treatment times for musculoskeletal conditions usually last 30-60 sec - Joules per point - Laser wand applicator held over tissue site until energy has been delivered - Joules per centimeters squared - Applicator applied in arcs across area of treatment Precautions & Contraindications Take Aways - Use of laser to promote positive photobiostimulatory eﬀect in tissue is laser therapy - Literature on use of laser therapy is conflicting - more consistent benefits when treating myofascial pain syndromes & promoting wound healing - Know the precautions & contraindications Activity: Discussion – Potential Energy 1. What is potential energy? force from attraction/repulsion of ions stored potential or capacity to do work, the greater the difference (cathodes/anodes) the more potential energy 2. What is a concentration gradient? creates the PE in an environment greater concentration gradient = more charge 3. How are these two related? important for skin electrical ions coming into skin influencing physiological mechanisms in the tissue low attenuation = conduct high attenuation = not conduct 2 3 4 1 Activity: Matching 1. 2. Phase 1. 2. The magnitude of a current or voltage with respect to the isoelectric line. b) How quickly a phase of current reaches maximum amplitude. c) How quickly a phase of current reaches the isoelectric line from maximum amplitude. d) Flow of current in one direction during a set period. e) One completion of a positive and negative series during a set period. Amplitude aka: intensity/magnitude 3. a) Rate of Decay Amplitude Frequency 3. Pulsed Current 4. Cycle f) Periodic cessation of electron flow during a set period. 5. Rate of Rise g) How many times one cycle of a waveform is completed per second. Activity: Waterfall – Therapeutic Electrical Stimulation (TES) Types Application 1. 2. 3. TENS NMES FES A Muscle Strengthening B Muscle Re-Education Pain Management 4. Microcurrent L Inflammation Management Pe Tissue Healing Activity: Break-Out Group Discussion – Applications of TES For each of the following clinical uses of electrical stimulation, be able to speak to when the treatment would be indicated and how it theoretically affects tissues. TENS 1. Pain Management chronic -never used in isolation gate control/descending inhibition 2. Muscle Strengthening 3. Muscle Re-Education NMES prevents atrophy -strengthen tissue that is in a deconditioned state Progressive overload - direct relationship b/w strength of current & strength gains FES denervation goal is not to strengthen - neuroplasticity 4. Management of Inflammation 5. Tissue Healing Microcurrent acute stage of healing - net positive charge chronic - negative Microcurrent Acute - prevention chronic - getting rid of inflammation through muscle pumps (permeability) Activity: Lecture – Electrical Waveform Breakdown higher intense = discomfort Waveform Pulse F Pulse D Amplitude Monophasic Gateway – High Central – Low Short Gateway – Low Central – High comfy Sensory Nerve pain management causing pain bc more skin impedance High Duration Gateway – Long this, decreased pain Central – Short following bc endogenous opiates Motor Nerve Bi/Polyphasic 20-80 Long Edema A – Mono C – Biphasic A – High C – 20-80 A – Short C – Long A – Low C – High 20-40 minutes High Short Low Long bc want to activate muscles Fatigue and task tissue perm a-acute c-chronic bc use muscle pump/contraction Healing Monophasic COMFY promote permeability for healing Frequency: 1. High frequency = more energy. 2. Skin impedance is lower at high AC frequencies; therefore, less electrical energy is dissipated in the skin and, consequently, there is less sensory stimulation and discomfort than with low-frequency PC. more comfy Activity: True/False – Special Current Types 1. Interferential can be used to control pain and stimulate muscle. TRUE/FALSE i needed this 1. Russian can be used to manage inflammation. Lol the flower muscle pump!!!! 1. TRUE/FALSE High volt electrical stimulation can be used to promote soft tissue healing. howww bc it triggers neutrophils and things (from what i remember) its on pg 7 for reference like it causes the push of the chemicals from the current? TRUE/FALSE yeah it causes biological stimulation?? i think thats what its called 1. Microcurrent is used to control pain. oki oki that makes sense thank u super low stim doesn’t stim a beta fibers TRUE/FALSE these classes killed me mentally today Activity: Waterfall – Application of Electrical Stimulation shave washing skin (non alcohol based products) checking pinleads/pigtails & adhesive each pt gets their own electrode size matches area being treated area being treated allergies to adhesives check skin before application document properly pt safety (contraindications) co-morbid conditions sensitivities implants Activity: Multiple-Choice Question – Diathermy Case Scenario Your patient is 8 weeks out of surgery which included a total hip replacement and implantation of metal hardware (plate and screws and metal loops) in his pelvis to stabilize a fracture. His chief complaint is stiffness and soreness around his affected hip, and you have read that diathermy may have some beneficial effect on pain and stiffness. What course of action do you take? a. b. c. d. Because the patient recently underwent surgery, you decide to use a monode applicator with 2 layers of terrycloth toweling. Because the patient’s pain and stiffness are severe, you decide to apply diathermy both at the beginning and the end of treatment to improve comfort. Because the patient’s chief complaints are pain and stiffness, likely of musculoskeletal origin, you decide to apply diathermy per standard protocol. Because metal surgical fixation devices are embedded in the patient, including metal loops, you decide not to use diathermy. bc electrical current heating up metal!! Activity: Multiple-Choice Question – Cold Laser Case Scenario In addition to positioning the patient appropriately, which of the following is appropriate when preparing a patient for laser treatment? a. b. c. d. Thoroughly clean the area with an alcohol swab. Use protective eyewear. Effectively cool the area with ice bath or the application of ice. Apply a coupling medium, such as a conductive gel to the treatment area. Activity: Discussion – Shockwave Therapy 1. When does the literature state that Shockwave Therapy should be used during normal stages of soft tissue healing? 2. Under what circumstances is it supported that Shockwave Therapy be used? chronic presentations of dysfxn

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