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Concepts Final Spring 2018
Terms in this set (244)
What are components of acute pain?
- symptom / warning
- well-defined time of onset
- pathology often identifiable
- objective signs of autonomic activity
- response to tissue injury
- has a biological function
- often relieved by treatment
- usually responsive to medication
- primarily involves the individual
what are components of chronic pain?
- pain is a disease
- ill-defined time of onset
- pathology often unidentifiable
- absent or adapted autonomic system activity
- response to peripheral and/or central changes in somasosensory pathways
- does not respond to treatment directed at pain
- less responsive to medication
- associated with depression, hopelessness, helplessness
- involves individual, family, social network, lifestyle
what are the temporal aspects of pain?
- date of onset
- 24hr behavior
- frequency of episodes
- constant vs. intermittent
what are modifying factors of pain?
what are some red flags of pain?
pain with fatigue
pain with weight loss
pain that is unfamiliar
what is paradoxical pain?
pain that is relieved but the problem worsens
ex: radicular pain is relieved as disc herniation progresses, but foot drop appears indicating greater compression
what are advantages of the three neuron pathway?
- assists in establishing location of lesion
- assists in management at the appropriate level
what are disadvantages of the three neuron pathway?
- does not account for many manisfestations of clinical pain syndromes
- does not account for referred pain
- does not account for variations in pain perception between individuals
What are the categories for first order neurons?
- polymodal receptors
- a beta low threshold mechanoreceptors
Where are nociceptors found?
skin, muscle, joint (capsule, ligaments, bone, periosteum, articular fat pads, around blood vessels), visceral
what are the phases of inflammation?
inflammatory, proliferative, maturation
what occurs during the inflammatory phase?
- clot formation
what occurs during the proliferative phase?
- fibroplasia/collagen production
- wound contracture
**too much scar tissue forms or in wrong place = lose ROM, mechanoreceptors fire
what occurs during the maturation stage?
- collagen synthesis/lysis balance
- collagen fiber orientation
What are A Delta High Threshold Mechanoreceptors (HTM)?
- free nerve ending
- mechanical stimuli (fire them)
- sharp, short response (faster)
What are A Delta Thermal Nociceptors?
- free nerve ending
- thermal stimuli
- sharp, short response (very fast)
What are C polymodal nociceptors?
- free nerve ending
- unmyelinated (longer to get to cortex)
- mechanical, thermal, chemical stimuli
- prolonged burning response (prolonged, throbbing, aching, you can get nauseous, etc)
what is nociceptor sensitization / what chemicals can sensitize?
- lowered threshold
- increased responsiveness
- prostaglandins, leukotrienes (sensitize)
- bradykinin, substance P, serotonin (activate nociceptors and sensitize them to further stimuli)
what is substance P?
- neurotransmitter in neuropathic and inflammatory pain
- localized in primary afferent fibers to spinal cord and some neurons of dorsal root ganglia (central/peripheral NS)
- in spinal cord, mostly in substantia gelatinosa
- decreases nociceptive threshold
what are A Beta Low Threshold Mechanoreceptors? (LTM)
- large diameter
- light touch, pressure, hair movement
What part of the spinal cord accepts sensory information?
What are Rexed's laminae / what occurs there?
- dorsal horn segregated into 10 laminae
- these laminae contain cell bodies of 2nd order neurons
- receive axons of incoming 1st order neurons
- substance P is believed to be neurotransmitter involved at synapse between 1/2 order neurons
- once they have synapsed, 2nd order neurons cross to opposite side of spinal cord and ascend in one of two central pathways
What are the categories of second order neurons?
- low threshold mechanosenstitive neurons (LTM)
- wide dynamic range neurons (WDM)
- nociceptive specific neurons (NS)
what are low threshold mechanosensitive neurons? (LTM)
input from low threshold innocuous stimuli like hair movement, touching
what are wide dynamic range (WDR) neurons?
input from nociceptive and non-nociceptive afferents
what are nociceptive specific (NS) neurons)
input from nociceptive afferents only
what are the ascending pathways of the anterlolateral system and where do they go?
-spinothalamic tract = thalamus
- spinomesencephalic = mesencephalon
- spinoreticular = brain stem reticular formation
**all along path of midbrain
what are the parts of the spinothalamic tract?
neospinothalamic = lateral
paleospinothalamic = anterior
**can make pitstop in midbrain (periaqueductal grey matter) to thalamus
what is the path / job of third order neurons?
- thalamus to somatosensory cortex
- pain is discriminated and localized
what is the reticular formation?
- diffuse cell network in medulla, pons, midbrain
- alertness, waking, sleeping
- motor, sensory, autonomic responses to noxious stimuli (sweating, elevated HR, nausea, vomiting, etc.)
what is the limbic system?
-receives afferent nerves from hypothalamus and brainstem
- descending influence from cortex
- motivational and emotional reactions
- visceral response to emotions
what are the levels of pain control?
examples of peripheral level pain control
-remove chemical irritants
-alter cell membrane permeability
-prevent abnormal tissue deformation
examples of spinal segmental level pain control
- spinothalamic (second order) = stop firing of second order neuron
- keep spinothalamic tract from firing
- stimulate A-beta's (hot pack, massage, mob, e-stim, etc) so A-delta/C can't fire
- stimulation of second order neuron by inhibitory neurotransmitter (GABA)
what is gait control theory?
balance of excitation-inhibition within T cells
- pre/postsynaptic inhibition of nociceptive afferents
- activatin of low threshold, large diameter mechanoreceptive afferents (a-beta)
- descending activation of SG cells
- enkephalin (inhibitory) interneurons block transmission of C fiber information within the T cell
- may involve various neurochemical inhibitory processes
- massage, joint mob, traction, e-stim, thermal agents
what are examples of supraspinal level of pain control?
beta endorphin modulation
what is central biasing?
- central biasing = impulses from higher centers are carried to dorsal horn to block pain transmission
what is endogenous analgesia?
- pre/post synaptic inhibition
- increase release of gamma-aminobutyric acid (GABA) in the PAGM and raphe nuclens (midbrain)
what are endogenous opioid peptides?
- neuromodulators that modify actions of CNS neurotransmitters
- naturally produced in the CNS and vrious glands such as pituitary and adrenal 3
1) endorphins = brainstem, hypothalamus
2) enkephalins (met-enkephalin, leu-enkephalin) = PAGM, medulla, dorsal horn of spinal cord
3) dynorphins = hypothalamus
**these neurons allow excitation of PAGM neurons
what is beta endorphin modulation?
- serotonin (5-HT) neurotransmitter
- implicated in inhibition / facilitation of nociception depending on site of action and receptor
- may excite / sensitize afferent fibers in inflammation and nerve injury
- during PAGM or raphe nucleus stimulation, inhibits incoming sensory activity
- may cause release of GABA and opiods
what are cortical level strategies of pain control?
- relaxation techniques
- guided imagery
- recognition of responses
- coping behaviors
what is the basic unit of radiant energy? how do you increase energy?
greater frequency, shorter wavelength
what are the physical behaviors of EMR?
what is the inverse square law?
intensity of wave varies inversely with square of distance between source of radiant energy and absorbing tissue
what is the cosine law?
max absorption of radiant energy = right angle from target tissue
what is the arndt-schultz principle?
optimum amount of energy absorption per unit of time that is beneficial
what is the law of grotthus-draper?
waves must be absorbed to be beneficial
what are biophysical effects of IR?
- increase metabolic rate
- increase blood flow, vasodilation
- increase tissue extensibility
- decrease muscle spasm
- decrease pain
what are properties of true laser diodes
- coherent (wavelength in phase)
- collimated (non-divergent)
properties of LED (light emitting diode) and SLD (supraluminous diode)
what is biomodulation/biostimulation?
stimulating or inhibiting biochemical, physiological, proliferative activities by altering intercellular activity
- increase in cell membrane permeability
- ATP production
- calcium channel effect
- macrophage stimulation
- fibroblast stimulation
- increase in DNA synthesis
- increase in levels of endorphins
what are different lasing mediums?
gas laser (HeNe) = 632.8nm
gallium arsenide (GaAs) = 904nm
gallium aliminum arsenide (BaAIAs) = 78-820-870nm**
which diodes are most used in clinical practice?
supraluminous = non-coherent
what are the parameters of EMR?
- power = rate of energy flow
- power density = power/unit area
- energy = power x time
- energy density = energy / area of irradiation
- expression = dose diode (per point energy delivered), dose-tissue (energy delivered)
what is dosage of EMR dependent on?
- output of laser in mW
- time of exposure in sec
- beam surface area of laser in cm2
what are treatment parameters of EMR?
- treatment time
- treatment area
- treatment technique (open wound, tissue close to skin, tissue with depth)
- treatment intervals
what are some clinical applications of EMR?
tissue healing / msk conditions
- soft tissue conditions
- carpal tunnel syndrome
- lat epicondylitis
what are contraindications of EMR?
- irradiation of the eyes
- within 6 mo radiotherapy
- over hemorrhaging areas
- locally to endocrine glands
- over neoplastic lesions
- over abdominal pelvic area during pregnancy
- over infected area
- photosensitive skin areas
- sympathetic ganglia, vagus nerve, cardiac region in pts with heart disease
- testicular region
over epiphyseal bone
what are the classes of lasers
1 = laser pointer, barcode reader
2 = laser pointer, therapeutic laser
3a/3b = therapeutic laser
4 = surgical laser
what is MIRE (monochromatic infrared energy) used for?
monochromatic near IR photo energy
- not coherent, not collimated, not a laser
- light induced vasodilation
- stimulate release of nitric oxide from hemoglobin
- nitric oxide important in microcirculation
- diabetic peripheral neuropathy
what are the types of UVR and what are they used for?
UVA/UVB = psoriasis (UVB more popular, goal = inhibit DNA synthesis)
UVC = wound healing
what are the biophysical effects of UVR?
- chemical = alteration of cell membrane function, excitation of cells, cell metabolism, DNA/RNA synthesis, protein/enzyme production
- alteration of ATP synthesis
what are the skin types / amount of burning?
I = white, always burn, never tan
II = white, always burn, tan minimally
III = light brown, sometimes burn, tan gradual
IV = mod brown, burn minimally, always tan
V = dark brown, burn rarely, always tan
VI = black, never burn, heavily pigmented
what are some adverse effects / eye risks of UVR?
phototoxicity, photoallergy, carcinoma, melanoma, skin aging, eye damage, burns, conjunctivitis, cataracts
what are precautions / contradindications of UVR?
- light sensitive skin
- photosensitizing medications
- history of skin cancer
- family hx of melanoma
- severe cardiac, kidney, liver disease
- previous rx with radiation
skin irritations, scars
what are the types of energy transfer / what are they?
- conduction = TOE through a medium
- convection = TOE with bulk movement of molecules (either liquid or gas)
- evaporation = TOE as liquid turns to vapor
- radiation = TOE though EMR
- conversion = TOE that involves converting non-thermal energy (ie vibrations) to thermal energy
what is thermal conductivity / examples of good/bad conductors?
- ability of a substance to conduct heat
- good = metal, bone, muscle, blood, water
- bad = fat, air, skin
what is the range for therapeutic temp rise / what depth constitutes superficial heat?
what are metabolic responses to heat / cold?
heat = increase metabolic rate, O2 consumption, production of met wastes, chemical activity, enzyme activity / phago
cold = decrease met rate, cellular energy needs, chemical activity, production of met wastes, enzyme activity /phago
what are vascular responses to heat / cold?
heat = increase vasodilation, capillary flow, cell perm, cell O2 / nutrient supply, rate of clearing metabolites, edema production, vascular congestion
cold = decrease tissue temp, reflex vasoconstriction of blood vessels through SNS, increased blood viscosity, dec blood flow, dec bleeding and removal of metabolic by-products
what are soft tissue responses to heat / cold?
heat = increase in contractile/non tissue extensibility, alteration in viscoelastic properties of collagen, decrease stiffness and resistance to movement, increase in flexibility
cold = increase in tissue stiffness, increase in resistance to movement, decrease in tissue elasticity, decrease in flexibility
what are neuromuscular responses to heat / cold?
heat = elevate pain threshold, decrease muscle spasm, alter nerve conduction velocity, alter muscle spindle firing rates, increase firing rate of type Ib afferent fibers from GTO's, decrease firing rate of type II afferents to muscle spindle, decrease in gamma efferent activity = decrease firing
**circulation = clears out chemotactic subsances, increased ROM = alleviate mechanoreceptors, a-beta = gait control theory
cold = decrease peripheral NCV, increase in strength short duration cold; alpha motor neuron facilitation, decrease in strength long duration cold; decrease in muscle spindle afferent discharge, decrease spasticity, reduce DTR activity
all thermo modalities / temp ranges
hot pack = 70-75*C
paraffin = 45-50*C
fluidotherapy = 110-127*F
inrared = right angle, at least 18in away
all cryo modalities / temp ranges
ice pack (freezer at -5*C)
intermittent cold (spray = 2-5 parallel sweeps, can 12-18in from skin
required testing for heat / cold?
heat = test tubes (50-55 cold, 91-95 warm)
cold = test tubes, ice-cube test, nail-bed test, BP
*positive ice cube = wheal within 5min after 3min massage
what is the progression for cold sensation?
deep, aching pain
pins and needles
contra/precautions for heat?
• Acute inflammation, edema, bleeding
• Areas of impaired sensation
• Poor thermal regulation (seniors, children)
• Thrombophlebitis, PVD
• Impaired mentation
• Areas of malignancy
• Cardiac insufficiency
• Over topical irritants
• Pregnancy: no full body immersion
• Open wounds: no paraffin
• Areas with metal: depth dependent
contra/precautions for cold?
• Cold hypersensitivity (cold urticaria, cold allergy)
• Paroxysmal cold hemoglobinuria
• Raynaud's disease
• Areas of impaired sensation
• Impaired mentation
• Psychological aversion or intolerance
• Circulatory compromise: PVD, HTN, CAD, seniors, children
• Over a superficial nerve
• Open wound
what are the types of ultrasound?
- US = conventional (soft tissue injury, wound repair, pain control, calcium resporption)
- LIPUS = low-intensity pulsed ultrasound (fracture/soft tissue repair)
- NCUT = non-contact, low frequency ultrasound (APWT = acoustic pressure wound therapy)
- ECSWT = extracorporeal shockwave therapy (chronic tendinitis, plantar fasciitis, kidney stones)
what are the characteristics of ultrasound?
- scattering (reflection, refraction)
what is beam non-uniformity ration (BNR), effective radiating area (ERA)?
BNR = ration of highest intensity found in the near field to average intensity
ERA = area of transducer from which US radiates
what are athermal mechanisms of US?
- acoustic cavitation = oscillation of gas filled bubbles in tissue, expand and contract = increased permeability
- acoustic streaming = unidirectional movement of fluid in US pressure field
what are the ranges of intensity for US?
- 0.1-0.5 = athermal
- 0.5-1.0 = mild thermal
- 1.0-2.0 = vigorous thermal
methods of coupling for US
- gel, lotion
- immersion (water)
- coupling cushion (bladder, water bag)
- gel pad
- sterile dressing (hydrogel, film)
proposed phonophoresis mechanisms
- dilate points of entry (sweat glands, hair follicles)
- increase local circulation
- increase kinetic energy of cells and medication
- increase cell membrane permeability
contraindications / precautions to US
• All previous heat precautions if thermal
• Area of a cardiac pacemaker
• Pregnancy (esp over lumbopelvic region)
- Acupuncture points
- Growing epiphsyses
- Over methyl methacrylate (acrylic bone glue)
- High-density polyethylene, plastic implants
- Over electronic implants
- Over a fracture site (Unless treating with LIPUS for fracture healing)
- Reproductive organs
- Over spinal cord post laminectomy
- Circulatory insufficiency
- Sensory impairment
- Skin areas exposed to radiotherapy
- Over cervical ganglia, stellate gangla or heart
Edema vs. Effusion?
edema = abnormal accumulation of fluid in intercellular tissue spaces (trauma, impaired circulation, heart failure, renal failure, lymph node resection, pregnancy, cirrhosis)
joint effusion = escape of fluid, cells and cellular debris from blood vessels with deposit into joint capsule (trauma, surgery, inflammation, infection)
what are functions of the lymphatic system?
- pores open to allow entry / flow of interstitial fluid, cell waste, proteins, extracellular particles into channels
- regulation of tissue fluid balance
- filters fluid and returns to blood stream
- normally aided by muscle activity, elevated positions, respiration, blood vessel pulsation
what are factors that promote edema?
- Increased permeability of capillary walls
- Increased capillary pressure due to venous obstruction or heart failure
- Altered renal function
- Decreased plasma proteins
- Inflammatory conditions
- Fluid and electrolyte disturbances
- Any condition that causes increased pressure in the blood or lymph vessels or decreased pressure in the interstitial tissues
- Traumatic edema
- Venous insufficiency
what constitutes traumatic edema?
= injury edema
- Cell death, bleeding and release of chemical mediators
- Vasodilation and increase in vessel permeability
- Local edema formed by plasma, plasma proteins, and cell debris from damaged cells moving into interstitial spaces
- Exudate forms too quickly for the lymphatic system to maintain local equilibrium
what constitutes chronic venous insufficiency?
- Abnormalities of the venous wall and valves
- Obstruction or reflux of blood flow in the veins and lymphatic circulation
- Compromise of surrounding tissue
- Hyperpigmentation, stasis dermatitis, chronic edema, and/or venous ulcers
what are consequences of edema?
- Decreased tissue oxygenation
- Tissue fibrosis
- Increased risk of infection
- Decreased ROM
- Cellulitis, dermatitis, ulceration, amputation
what are goals of compression therapy?
• Increase external pressure
• Decrease pressure gradient between blood vessels and tissue
• Discourage capillary bed leakage
• Improve fluid balance
• Modify scar tissue formation
what are clinical indications for compression therapy?
- Venous insufficiency
- Stasis ulcers
- Traumatic edema
- Amputation: Residual limb shaping
- Hypertrophic scar management (burns)
- Post-mastectomy lymphedema
- DVT Prevention: Post-operative
- Venous stasis
- Endothelial injury
- Hx of DVT
- Hormone treatment
- Recent leg surgery
- Varicose veins
- Varicosity management during pregnancy
what are clinical effects of compression?
- Increase venous circulation
- Increase lymphatic circulation
- Control peripheral edema
- Promote healing of venous ulcers
- Prevent DVT
what are the types of compression?
what are options for compression delivery?
- compression bandaging
- manual lymphatic drainage
- compression garments
- compression aids
- compression braces/ bands
- static compression unit
- intermittent pneumatic compression pump (inflatable garments)
what are the modes of compression delivery?
- uniform (single chambered)
- sequential (always distal first)
what are precautions / contraindications to compression?
- Acute trauma, fracture
- Compartment syndrome
- Congestive heart failure
- Acute pulmonary edema
- Acute infection
- Recent/acute deep vein thrombosis
- Cardiac, kidney dysfunction
- Obstructed lymphatic channels
- Impaired sensation/mentation
- Arterial insufficiency ulcers
- Correct application
- ankle brachial index
how is ankle brachial index measured / what is limit for compression?
highest ankle doppler pressure / highest brachial doppler pressure
all patients being evaluated for PVD should have ABI measured
compression contraindicated if ABI is less than 0.8
what is microwave diathermy?
strong electrical field, minimal magnetic field
- problem = high electrical component, less penetration, high risk of overheating, many contraindications, seldom used
what are the characteristics of shortwave diathermy?
- electric and magnetic fields which alternate at high frequencies
- continuous or pulsed = thermal or athermal
what are the biophysical effects of diathermy (describe them)?
- ionic motion = primary mechanism for converting high-frequency current into heat
- dipole rotation = water molecule (pair of equal and opposite charges separated by small distance) rotating when exposed to high-frequency oscillating EM fields
- electron-cloud distortion = non-polar molecules causing minimal friction
what are good / bad conductors for diathermy?
- good (low electrical resistance) = muscle, synovial fluid
- poor (high electrical resistance) = fat, bone, skin
what are the methods of producing diathermy?
condenser (electric, capacitive) field
inductive (magnetic) field
what are the components of a condenser field?
- strong electrical field
- condenser, air-spaced plates
- tissues with high conductivity allow passage of the field
- tissues with low conductivity store electrical charge
what are the components of an induction field?
- can have capacitator plates or coil-rubber plates
- all inductive applicators are made of a coil through which current flows
- current produces magnetic field which includes oscillating eddy currents in tissues
- friction causes the thermal and athermal effects
- less heating of subcutaneous tissue
what are the nonthermal physiological effects of diathermy?
- Repolarization of damaged cells
- Acceleration of cell growth and division when slow, inhibition when fast
- Reestablishment of sodium pump
- Increased microvascular perfusion
- Improved cell function
what are the thermal physioligical effects of diathermy?
- Tissue temperature rise
- Increased metabolic rate
- Increased blood flow
- Increased membrane diffusion
- Muscle relaxation
- Decreased pain
- Increased collagen extensibility
- Hematoma absorption
what are the dose categories for PSWD, what are they for, heat perception?
- Dose 1 = acute, no heat perception
- Dose 2 = sub-acute, mild heat perception
- Dose 3 = chronic, comfortable heat perception
- Dose 4 = max tolerable heat perception
• All heat precautions if thermal
• Metal implants
• External metal in field
• Electromedical devices
• High fluid volume areas
• Moist wound dressing
• Synthetic substances, ie, plastics, nylon
• Altered mental status
• Over testes
• Over eyes
• Neoplastic lesion
• Growing epiphyses
• Sensory impairment
• Hemorrhagic region
- Menstruation (abdominal/pelvic region)
• Electronic or magnetic equipment in the field; at least 1 m away
• Operator > 1 m from CSWD applicators
• Operator 30-50 cm from PSWD applicators
• Pregnant operators should abstain
• Immediately following superficial heat or cold application
PSWD contraindications / precautions
- Implanted stimulators and electronic equipment: Contraindicated (even if the device is not turned on; FDA, 2002)
- Treatment may be thermal dependent on parameters; previous precautions and contraindications would be respected
what are the different channel timings of EMG?
- continuous mode
- synchronous mode (on off times)
- reciprocal mode
what is EMG current density?
- ration of max current amp to electrode stimulating surface area
- higher the current density, greater the discomfort
- mono = only one of two essential leads (one or two electrodes) is placed over target area (stimulating/treatment electrode), other lead is dispersive/non-treatment
- bi = both essential leads are connecting electrodes (2+) placed in target area
- quad = typically utilized with IFC, current from 2 circuits is delivered with 4 electrodes in criss-cross or parallel arrangement (allows mixing of currents)
what is a motor point? (clinically vs. anatomically)
clinically: a specific skin area where the targeted muscle is best stimulated with the least amount of current amplitude and shortest pulse duration
anatomically: the surface entry point of a bundle of motor nerve fibers into a fascicle of muscle fibers
what are the types of direct current?
- direct current
- interrupted direct current
what are the components of HVPC?
- twin peak, monophasic pulsed current
- effective phase duration 5-20microsec
- least amount of total average current with this because of short duration and long interpulse interval in between
- don't have to be afraid of high voltage (500V usually)
what are the components of IFC?
- amplitude modulated, sinusoidal, symmetrical, biphasic alternating current
- beat or envelope frequency secondary to amplitude modulation of AC (alternating current) carrier frequencies (ie 4000, 4100)
- quadripolar or premodulated
what is sweep vs scan (IFC)?
- sweep = frequency modulation (more specific, smaller area)
- scan = changes location (vector scan on, targets larger area, less specific)
what are the options for biphasic symmetric pulsed current?
TENS = symmetrical biphasic
VMS = symmetrical biphasic with interphase interval
VMS Burst = symmetrical biphasic with burst timing
what are the options for biphasic asymmetric pulsed current?
TENS asymmetrical biphasic
what are the frequencies that make up russian current?
what are the time dependent characteristics of EMG?
- phase duration
- pulse duration
- interpulse interval
- interphase interval
- interburst interval
what are the different modulations?
- phase or pulse duration
what are the types of ramping / what are they called?
- amplitude ramping = scanning
- frequency ramping = sweeping
what is the formula for % duty cycle?
time on / (time on + time off)
what are the clinical capabilities of EMG?
- electroanalgesia (pain management)
- neuromuscular dysfunction (muscle dysfunction = NMES, FES, EMS)
- joint mobility
- acute and chronic edema management
- peripheral blood flow
- tissue repair
- urinary and fecal incontinence
what are charges of cations, anions, cathodes, anodes?
cations = +
anion = -
Cathode = -
anode = +
ampere vs. milliampere
ampere = unit of current, rate at which charge flows past a fixed point in a conductor
milliampere (ma) = 1/1000 of an ampere, commonly used in Estim
what is resistance vs. capacitance vs. impedance?
- resistance (measured in ohms) = opposition to current flow of charged particles
- capacitance (measured in farads) = degree in which electrical charge is stored in the system
- impedance (measured in ohms) = resistance to flor of current that is frequency dependent (takes into consideration resistance and capacitance) (as frequency increases, there is less storage of charge)
what is ohm's law?
voltage = current x resistance
current = voltage / resistance
What are the parameters for HVPC?
what are the components of voltage/current?
- low voltage
- direct current
what are the parameters for microcurrent electrical stimulation (MES)?
pulsed current, <1mA or 1-999microamps
what are the parameters for low intensity direct current (LIDC)?
continuous direct current <1 mA
what are the physiological responses of electrical current through the body / what happens with each?
1 - electrothermal = vibration of charged particles leads to heat production, not desired
2 - electrochemical = creation of HCL, increase in acididity, etc., most notable during continuous DC (ionto), excessive = blistering and burns
3 - electrophysical = excitatory (sensory, motor, pain - action potential), non-excitatory (alter ion movement across cell membranes, enhance DNA and protein synthesis, alter enzymatic activity, modify fibroblast, osteoblast formation, migrate epidermal cells)
what are components of the strength duration curve?
- current must be sufficient amplitude and duration to bring excitable cells to threshold
- sensory, motor, painful stim are basic excitatory responses
- fibers with largest diameter and lowest resistance are most easily excited
- excitation can occur as long as threshold is reached for that nerve fiber
what is rheobase vs. chronaxie?
- rheobase = minimum current aplitude required to produce an AP
- chronaxie = minimum duration it takes to stimulate that tissue at twice the rheobase intensity
what are the types of current / their babies?
- direct current (continuous reversing, ramped, interrupted)
- alternating (continuous, IFC, russian)
-pulsed current (monophasic, twin peak monophasic = HVPC, biphasic PC)
what are the parameters of IFC?
- medium frequency: 1000-10,000Hz
- beats of IFC at low frequency ranges of 1-200 beats/sec
- frequency = amplitude modulated or beat frequency, equal to difference between frequencies of two circuits
- constant = constant difference between frequencies of 2 circuits = constant beat frequency (1-120bps)
- total current = 90-100mA
what are the parameters of russian current?
- 50% duty cycle
- 25 cycles/burst = burst modulated
- total current 100mA
- peak current 200mA
what is the definition of pulsed current?
- an isolated unit of uni or bidirectional movement of charged particles separated by a finite period from another unit of charged particle movement
what is the total current of biphasic PC?
what size muscle groups correlate with which symmetry of phase?
asymmetric = smaller muscle groups
symmetric = larger muscle groups
balanced vs. unbalanced phase charge
balanced = phase charges of each phase are equal = zero net charge
unbalanced = phase charges of two phases in one cycle are unequal and net charge differes from zero
what are the different waveforms or phase shapes?
what are the quantitative characteristics of amplitude?
- peak amplitude (zero to peak amplitude, peak to peak amplitude)
- RMS amplitude: current or voltage applied over a specified length of time
- average amplitude
phase duration vs. pulse duration?
duration of a phase
time elapsed between the beginning of the first phase and the end of the second phase of a pulse
rise time vs. decay time?
rise time = time it takes to go from baseline to the peak amplitude
decay = opposite
interpulse interval vs. intrapulse interval?
time elapsed between two successive pulses
= interphase interval, basically
period vs. frequency?
period = reciprocal of frequency
frequency = number of pps for a PC, Hz for an AC
what are the different types of modulation?
- peak amplitude
- phase duration
- pulse duration
what is the definition of a train?
- a continuous, repetitive series of pulses or a segment of AC is called a train
what is the definition of a burst?
- a finite series of pulses (PC) or interval of AC delivered at a specified frequency over a specified time interval
what is the definition of frequency for PC / AC?
- PC = number of pulses per second (pps)
- AC = number of cycles per second (Hz)
what are the low/high frequency limits for TENS?
low = < 10 pps or Hz
high = > 50 pps or Hz
what are the low/high frequency limits for NMES?
low = 1-1,000 pps or Hz
medium = 1,000-10,000 pps or Hz
high = >100,000 pps or Hz (thermal)
what are the different levels of stimulation?
what are physiological changes of electrotherapy for pain management?
- gate control theory
- opiate mediated
- descending inhibition
- acupuncture theory
- spinal nerve block
- local vasodilation to ischemic tissues
what are options for subsensory level electrotherapy for pain?
- microcurrent (MENS, MES)
- low intensity direct current (LIDC)
what are the components of microcurrent?
- monophasic or biphasic PC
- tsunami, slope, square wave
- polarity = +, -, or "alternating"
- polarity (+) = skin, tissue repair
- polarity (-) = bone, nerve repair
what are the parameters of microcurrent?
- 50% duty cycle
- peak intensity < 1mA
- average intensity 200-300 microamp
- frequency 0.1-990 pps
what are the non-excitatory proposed mechanisms of microcurrent?
- opening of ion channels: mobility of sodium, calcium, potassium
- increased ATP production and amino acid transport
- enhancement of DNA, protein synthesis
- stimulation of cellular physiology
- alteration of bioelectric voltage potentials across cell membranes
What are the different TENS stimulation modes, and which are sensory / motor
- conventional (high rate / high frequency) = sensory
- acupuncture-like (low rate / low frequency) = motor
- burst modulated (burst train, pulse burst) = motor
- brief intense = motor
- hyperstimulation (noxious) level TENS = motor
- modulation = sensory
- wedensky inhibition = sensory
what is the goal / components of conventional TENS?
- spinal cord gating (gait control theory)
- activation of large diameter peripheral A beta fibers to produce segmental spinal analgesia
- rapid onset and offset localized to the dermatome
- carryover is short
- effectiveness can be modified (modulations are often necessary)
what are the components of wedensky inhibition?
- loss of excitation caused by maintaining a continuous refractory state
- frequency > 1000pps
- sensory level
- short duration
- electrode placement over local peripheral nerve
- goal is to keep exciting peripheral nerve so that it can't notice pain
- prolonged repetitive stimulation at supramaximal frequency causes the nerve to temporarily cease conducting - accomodation is responsible and is caused by an increased threshold and fatigue of synapses
what is the goal / components of acupuncture like TENS?
- goal = produce extra-segmental analgesia through the activation of descending pain inhibitory pathways (endogenous opiate-mediated systems)
- stimuli introduced into the CNS appear to initiate series of events leading to release of endorphins (stimulation of hypothalamus)
- small diameter A delta fibers are stimulated, as well as alpha efferents to produce a strong muscle twitch
- onset of relief is 20-30min
- analgesia is more long lasting than conventional TENS
- adaptation to stimulus is usually minimal
what is the goal / components of burst modulated TENS?
- goal = similar to acupuncture-like: endogenous opiate-mediated
- burst mode uses combination of high frequency carrier and low frequency bursts that may be perceived as more comfortable than acupuncture-like TENS
- motor response is required in segmentally related area
- pulsed or alternating current may be burst modulated
- modification of acupunture-like TENS
- amplitude = adjust to produce visible muscle twitching
what is the goal / components of brief intense TENS?
- goal = activate small diameter peripheral delta fibers by delivering TENS over peripheral nerves arising from the site of pain at an intensity just tolerable
- physiological mechanism is activation of A delta afferents to produce peripheral blockade of nociceptive afferent activity
- intense TENS is used for short durations only
- strong paresthesia, slight muscle contraction
what is the goal / components of hyperstimulation (noxious) level TENS?
- goal = produce painful stimulus in or remote from painful site that will trigger systemic endorphin-mediated mechanisms
- noxious stimuli excite pain fibers leading to activation of reticular formation and PAG
- PAG activates descending inhibition at the spinal cord level modulation called "hyperstimulation analgesia"
- noxious level TENS is most often used only if other modes of TENS are unsuccessful or accommodation has occurred
- burning, needle like sensation to tolerance
- it's like trigger point technique
what is the goal / components of modulation mode?
- goal = variation of one of the regular patterns altered to reduce accomodation
- especially useful in patients who use TENS for extended periods of time
- may vary frequency, duration, amplitude, or some combination based on manufacturer
GENERAL progression of TENS modes
conventional (then modulate if accomodation -> burst or low rate
- use brief intense and hyperstimulation for specific applications
what is the relationship of frequency to phase duration to skin impedance to effectiveness?
- higher frequency = shorter phase duration
- shorter phase duration = lower skin impedance
- tissue impedance is reduced by any device that allows pulses with durations in the range of 100 microsec
what is the benefit of using IFC over other types of waveforms?
- critical factor is adequate charge for depolarization, not frequency
- a major difference between IFC beats and pulses is that beats deliver much higher maximum total current to the tissues
what are the options for electrode placement?
- area of pain
- motor point
- trigger point
- acupuncture point
- peripheral nerve
- nerve root
what is an acupuncture point?
- pathways (meridians) flow from organ system to organ system
- meridians are channels of energy or chi
- along pathways, are points close to skin surface
- when stimulated, these "acupuncture points" cause events that affect many aspects of mind, body, spirit
what is a trigger point?
- hypersensitive palpable nodule in a taut band
- pain in a characteristic zone of reference
- passive or active stretching of the muscle increases pain
- limited range of motion
- pain with resistance
what is the general TENS process?
- evaluate nature, location, possible structural sources of pain
- OSS electrode placement based on anatomic and physiologic factors
- begin with conventional mode and assess benefits with supervision
- adjust stimulation parameters
- IF INEFFECTIVE = alternative electrode placement
- parameter modulation
- alternative mode of TENS
- home instruction = equipment, body diagram, TENS diary
what are the clinical indications of combination US/ES?
- decrease muscle spasm
- trigger point therapy
- relieve pain
- increase local circulation
- promote tissue healing
what are the contraindications / precautions to ES?
- Demand cardiac pacemaker
- Electronic implants
- Undiagnosed pain
- Cardiac disease, arrhythmias
- Anterior transcervical area
- Carotid sinus, vagus, phrenic nerves
- Thrombophlebitis, arterial or venous thrombosis
- Near operating SWD
- Abdomen, lower back
- Acupuncture points (LI4: 1st dorsal interosseous, BL60: behind lateral malleolus, BL67: lateral aspect small toe, SP6: above medial malleolus)
- Skin irritation
- Altered sensation
- Hemorrhagic area
- Over the eyes
- Seizure disorder
- Altered mentation
- Monitor patients taking narcotic meds
what are the different types of E-stim for muscle activation?
- NMES (neuromuscular electrical stimulation) = activation of muscle through stimulation of intact peripheral nerves
- FES (functional electrical stimulation) = NMES with functional activity
- EMS (electrical stimulation) = direct activation of denervated muscle
- ESTR (electrical stimulation for tissue repair) = EMS to promote circulation and wound healing
what are the physiological principles for NMES?
- all fibers in a particular motor unit are the same type
- proprotion of different motor units varies betweenmuscles
- slow twitch fibers (type I - low-level, sustained contractions)
- fast twitch fibers type II
- fatigue resistant type IIA =
short duration, low force
- fast-fatigable type IIx =
short duration, forceful
- motor neuron, NOT muscle fiber activation with NMES
- recruitment increases the # of muscle fibers and force output
- recruitment based on fiber size and proximity to electrode
- electrically induced contractions are synchronous
- electrically induced contractions excite large diameter, fast twitch fibers first = more fatiguing
- sensory nerves (a-beta) and pain fibers (a-delta) are stimulated
- isometric and isotonic contractions can be produced
what is the pattern of recruitment for NMES and potential limiting factors?
- stimulus at an amplitude and duration just above threshold = closest and largest fibers + greater stimulus = smaller fibers close to electrode, as well as larger fibers farther away
- limiting factors = perception of discomfort, muscle fatigue
what is a limitation of HVPC with NMES?
low total current may be inadequate for forceful large group muscle stimulation
what are two types of BMAC for NMES?
what is a limitation of pre-modulated IFC for NMES?
unnecessary high total current, fixed phase duration, may or may not have variable on:off
biphasic pulsed current: symmetrical or asymmetrical?
- depends on the muscle size
- large muscle groups = symmetrical
- small muscle groups = asymmetrical
desired contraction components for NMES?
- for most programs, tetanic contraction is desired
- as frequency increases, firing rate increases, increasing fatigue
- minimum frequencies range from 15-50pps (average 30-35pps)
- tetanic ES contraction more fatiguing than normal contraction (same nerve fibers are stimulated repeatedly)
- use minimal frequency which produces tetany especially if prolonged stimulation anticipated
- tetany may be evaluated through visualization of motion and muscle palpation
patients find higher frequencies more comfortable; longer off times are necessary with increased frequencies
- with med freq current, greater current amplitude is necessary
- increases in duty cycle of bursts (increase in burst duration) may contribute to decreases in magnitude of response
on:off time - what studies show
- longer on times = increasing isometric strength
- dependent on pt goals
- longer off periods should be considered if very high amplitudes or stimulation frequencies are being used
what are the three patterns of synchronization?
- simultaneous (immediate activation of 2 muscle contractions)
- reciprocal (alternating activation)
- delayed (offset)
what is volition?
- stimulation without volition = muscle relaxed during ES
- stimulation with volition (superimposed method) = application of ES with voluntary contraction
what are components of optimal electrodes / placement?
- promote low skin impedance
- conduct current uniformly
- maintain uniform skin contact
- allow desired part movement
- minimize skin irritation
- cost effective
- size and shape variety
- motor point = usually optimal
- parallel to muscle fiber direction
- large electrodes for large muscles / vice versa
- increased distance b/w electrodes increases current flow depth
what are clinical indications for NMES?
- strength training
- re-education / facilitation
- ROM/contracture management
- edema management
- orthotic substitution
- spasticity management
- incontinence management
- gait training
What are the components for NMES for strength / re-education?
- amplitude = max tolerable to produce desired ROM
- waveform = biphasic pulsed or burst-modulated AC
- number of contractions/session = 10-20 at max intensity, 2-3x/day
- frequency of sessions = 3-7x/wk
- rate of fatigue is greater during NMES than voluntary contraction
what are the differences / proposed rationale in acute edema retardation vs. post-acute (chronic) edema reduction?
- sensory level, NOT NMES
- proposed rationale = reduction of microvessel permeability to plasma proteins, enhanced lymphatic uptake of proteins, possible related to alterations in blood flow
- motor level, NMES
- proposed rationale = mechanical effects of muscle contractions to pump fluid from vessels
what are the components of NMES for ROM (comfort)?
- low impedance
- low net charge
- biphasic waveforms usually preferable
- small muscle groups = asymmetrical, large = symmetrical
- gradual ramping
- high frequency initially (reduce due to fatigue)
- less volitional effort with greater amplitude
what are contraindications to NMES?
- Demand cardiac pacemaker, known arrhythmias
- Over the carotid sinus
- Venous or arterial thrombosis/thrombophlebitis
- Indwelling phrenic nerve/bladder stimulator
- Near operating SWD
- Regions of neoplasm or infection
- Over abdominal, LS, pelvic regions during pregnancy; caution to all regions
- Over an open wound
- Over the craniofacial or cervical region of patients with hx of CVA or seizure
- Over the eyes
what are precautions to NMES?
- Tissues vulnerable to hemorrhage
- Skin irritation or damage
- Thoracic regions in patients with cardiac hx
- Hypo or hypertensive patients
- Impaired mentation
- Impaired sensation
- Uncontrolled ballistic movements
- Obesity or areas of excessive adipose
- Osteoporosis or spontaneous fracture site
- Near protruding metal
- Over fragile skin, sutures
what are the different components of learning / define them?
- stimulus input (visual, auditory, proprioceptive, etc.)
- stimulus identification (recognize that a stim has occured and is important)
- response selection (what are you going to do with that stimulus?)
- response programming (creation of neural code/program)
- retention (move from short to long term memory)
- feedback: precise, relevant, immediate (motivation, reinforcement)
what are the criteria to use biofeedback?
- potential to voluntarily control movement
- cognitive awareness
- information gained would be useful for re-education or relaxation
what is an EMG recording vs. amplitude?
- recording = electrical activity of muscle membrane in response to activation of skeletal muscle (AP)
- amplitude = size and number of active motor units, distance of the active muscle fibers from the recording electrodes
what are the components of high amplification?
- more sensitive
- low microvoltages
- display minimal MUAP's
what are the components of low amplification?
- less sensitive
- high microvoltages
- display many MUAP's
components of re-education vs. inhibition
- re-education = decrease gain (measured by device) as recruitment improves
- inhibition = increase gain (measured by device) as relaxation improves
what is the definition / components of common mode rejection ratio?
- differential amplifier will subtract extraneous noise detected by one active elctrode from noise detected by the other
- true difference between electrodes
- higher CMRR for lower noise
what are examples of electrical signals that are not part of the wanted EMG signal?
- equipment noise
- electrical noise
- mechanical artifact
- volume conducted artifact
what is the purpose of filtering?
- screen out unwanted signals whose frequencies are too high or low
what is bandwidth?
the difference between the lowest and highest frequency response
what is time constant (TC) and parameters for short / long?
- sampling frequency of the EMG signal and how frequently that information is relayed to the viewer in the form of an EMG signal
- short = 0.1s (dynamic movement)
- long = 0.5-1s (static activity / postural changes)
what is threshold?
- predetermined level of muscle activity at which audio and/or visual feedback is provided
- altered by clinician to achieve recruitment or inhibition
how do you set recruitment vs. inhibition?
recruitment = just above baseline level of voluntary motor response
inhibition = set initial threshold just below level of perceived relaxation
what are the different modes of feedback?
- work-rest (on-off)
what are areas to avoid / areas to specify for biofeedback electrode placement?
- avoid tendon, motor point, outer edges of muscle, adipose
- specify parallel to muscle fiber length, over or near muscle belly
what are examples of EMG recording / things to look out for?
- normal resting tone
- slow twitch evaluation
- fast twitch evaluation
- low net rise
- elevated tone between contractions
- hypertonus with low net rise
what are the components of uptraining (when would we use it)?
- INTERVENTION = RECRUITMENT
- peripheral nerve injury
- MSK impairments (ie weakness) secondary to immobilization, surgery, pain
- gait impairments
what are the principles of biofeedback recruitment?
- evidence of re-innervation
- high sensitivity to low sensitivity
- narrow interelectrode distance for specificity
- minimize abnormal movement patterns
- minimize fatigue
- consider NMES interfacing
- incorporate functional activities
= SEMG triggered NMES
what are the components of relaxation (when would we use it)?
INTERVENTION = RELAXATION
- muscle spasm
- repetitive strain injury
- stress related disorders
what are cognitive behavioral methods of relaxation?
-Jacobson's progressive muscle relaxation
- Schultz's autogenic training
- guided imagery
what are all the methods of measuring relaxation with biofeedback?
- galvanic skin response
- blood pressure
- heart rate
- ergonomic assessment
- workstation assessment
- sEMG biofeedback assessment
what are different factors that influence learning with sEMG?
- instruction prior to practice
- goal setting
- intention of the practice
- motivation (both parties)
- amount of practice
what are advantages to biofeedback?
- provides clear goal and motivation for pt
- reinforces appropriate motor behavior
- knowledge of results is timely and accurate
- sensitive to small changes in muscle activity
- technique is painless, easy to perform
- assists in identifying substitution patterns
- quantitative information for docu
- internal level information
what are limitations to biofeedback?
- inability to isolate certain muscles
- potential for noise contamination
- not a measure of muscle force, strength or ability to perform ADLs (info should not be over interpreted)
- electrodes may alter a movement pattern
- equipment may be costly
what's the definition of iontophoresis?
- introduction of substances into the body for therapeutic purposes by means of an electrical current
what are the primary effects of ionto / describe them?
- phoretic = drug transfer due to capacity of electrical current to move drug ions through the stratum corneum
- electrolytic = formation of new compounds, redox reaction, skin pH shift, sclerolytic or sclerotic reaction
- pharmacologic = effect dependent upon the active ingredient contained in the drug
what is the stratum corneum / components of it?
- most superficial layer of skin
- barrier to environmental and infectious insults
- primary barrier to diffusion
- forms the high electric resistance layer and component to skin impedance
- limits the number of molecules that can be delivered
what is the pathway of ion transfer?
- ionizable substance (acid, base, salt, alkaloid)
-> ionization (dissociation into component ions)
-> continuous DC (migration of ions)
-> (+) ions repelled from anode, (-) ions repelled from cathode
what is a redox reaction / where does it occur?
- water decomposition using electricity
- reduction/oxidation of water
- reduction occurs at cathode
4 H2O + 4e- = 2H2 + 4OH-
- oxidation occurs at anode
2H2O = O2 + 4H+ +4e-
what are the components of the skin pH shift with ionto?
accumulation of hydrogen ions (H+) = pH decrease, acidic, anode (oxidation)
accumulation of hydroxyl ions (OH-) = pH increase, alkaline, cathode (reduction)
what are potential problems with the pH shift?
- alteration of electro-osmotic flow effecting ionizatio and medication transfer
- alteration in skin charge leading to skin irritation and burns
what are the components of buffers?
- designed to reduce the harmful effects of acid-base pH changes that occur with ionto
- chemicals or resins "buffer", or absorb, excessive H+ or OH- ions to reduce pH shifts
what occurs at the anode (ionto)?
- attraction of (-) ions
- sclerotic = hardening
- water oxidation -> H+
- acid reaction by formation of HCL (2Cl + 2H2O -> 4HCl + O2)
- decrease skin pH
what occurs at the cathode (ionto)?
- attraction of (+) ions
- sclerolytic = softening
- water reduction -> OH-
- formation of hydroxide base NaOH (2Na + 2H2O -> 2NaOH + H2)
- increase in skin pH
is NaOH or HCl more caustic?
NaOH = more caustic or susceptible to burns
what are the different target tissues for ionto, average penetration, and absorption?
- skin, superficial muscle, tendon, bursa
- penetraion = 1-3mm average
- absorption = circulation, transmembrance (up to 20mm)
what are variables of target tissue (ionto)?
- drug type
- drug concentration (higher conc = increased uptake til plateau)
- current intensity / duration (high current may deliver more drug due to inc skin permeability - pt tolerance = constant is best)
- current density (watch for skin sensitivity)
- competing ions (shift in pH may result in loss of efficiency of drug transfer)
- pH of environment (ideal to have as much drug possible in ionized state - but watch out for pH tolerability)
- anatomical variables (adipose, skin thickness, other tissues)
- inflammation (inc temp/fluid levels = increased penetration rate)
what are some examples of therapeutic ions / what they do?
- chloride (-) = sclerotic
- copper (+) = anti-fungal
- acetic acid (-) = decalcifying agent
- magnesium (+) = muscle relaxant
- lidocaine (+) = local anesthetic
- Dexamethasone sodium diphosphate (-) = Most commonly used anti-inflammatory
- Iodine (-) = Sclerolytic, antimicrobial
- Hyaluronidase (+) = Antiedema
- Lithium (+) = Gout
- Salicylate (-) = Anti-inflammatory, analgesic
- Ketoprofen (-) = Anti-inflammatory
- Tap water (+/-) = Anti-sweating agent
what is the best delivery for Dexamethasone sodium diphosphate (DmNaP)?
- most efficient from negative electrode (ionto)
- some delivered from anode (electroosmosis)
what are general electrode components for iontoporesis?
- continuous DC
- clinical or portable
- current intensity usually 1-5mA
- cearly marked polarity terminals
what is the formula for ionto dosage?
current (mA) x treatment duration (min) = mA-min
what are advantages to ionto?
- local action
- no 1st pass metabolism as with NSAIDs
- easy treatment termination
- less invasive than injection
what are disadvantages to ionto?
- skin barrier
- less drug absorption and depth of penetration
- precise dosage delivered unknown
what are precautions / contraindications to ionto?
- Drug allergy
- Demand cardiac pacemaker
- Over thoracic region
- Over the eyes
- Skin irritation, broken skin
- Altered sensation
- Altered mental status
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