Therapeutic Modalities SVU Workshop 2024.pdf

The most important Electrophysical agents in Physical Therapy Practice

2. FUNDAMENTALS OF
ELECTROTHERAPEUTIC
MODALITIES
SVU WORKSHOP
AND
RELATEDQUESTIONS

3. Dr. Mohamed G.A. Ali Shehata
BSc PT, MSc PT, PhD PT
Lecturer of Physical Therapy, SVU, Egypt
Associate Alumnus, Harvard Medical School, USA
Former PhD researcher, SRT, Queen's University,
Ontario, Canada

4. Objectives of this lecture
*By the end of this lecture, the Physical Therapist acquires the knowledge of:
A)UnderstandthePrinciplesofElectrophysicalAgents:Understandthe
basicprinciplesofElectrophysicalagents,including:heatandcoldtherapies,
electricalcurrent,therapeuticultrasound,andotherrelatedconcepts.
B)UnderstandDosageandTreatmentParameters:Grasptheimportanceof
dosageandtreatmentparametersforElectrophysicalagents,including
considerationsforintensity,duration,andfrequency.
C)DemonstrateApplicationTechniques:Demonstratepropertechniquesfor
applyingElectrophysicalagents,ensuringasafeandeffectivetreatment
approachindiversepatientpopulations.
D)DiscussIndicationsandContraindications:Thatmayaffectapplication.

5. Superficial Thermotherapy
*Heatcanbetransferredintheseways:byconduction(Hotpacks,Paraffin),by
convection(Fluidotherapy,Whirlpool),andbyradiation(InfraredLamps).

6. INCREASED
Decreased
Physiological Effects of GeneralHeatApplication
Increased Decreased
Cardiac output Blood pressure
Metabolic rate Muscle activity (sedentary effect)
Respiratory rate Blood to internal organs
Pulse rate Blood flow to resting muscle
Vasodilation Stroke volume

7. IncreasedPhysiological Effects of LocalHeat Application
System/Structure Mechanism
Blood flow Dilation of arteries and arterioles
Capillary permeability Increased capillary pressure
Elasticity of tissuesIncreased extensibility of collagen tissue
Metabolism For every 10°C increase in tissue temperature,
the rate of cellular oxidation increases by two
to three times
Vasodilation Release of vasoactive agents
(Bradykinin, Histamine, Prostaglandin)
Edema Increased capillary permeability

8. DecreasedPhysiological Effects of LocalHeatApplication
System/Structure Mechanism
Joint stiffnessIncreased extensibility of Collagen by enhancing the
action of Collagenase enzyme and decreased viscosity
Muscle strength Decreased function of glycolytic process
Muscle spasm Increased firing of Golgi tendon organ and Decreased
firing of muscle spindle which decreases alpha motor
neuron activity
Pain Gate control theory: Stimulation of thermoreceptors
that activate Beta sensory nerves and block pain
signals transmitted through either A-delta or C nerve
fibers & Disruption of pain-spasm cycle

9. Superficial heating physical agents
A)Hotpack:Acanvaspackfilledwithsilicagel,heatedbyimmersionin
waterbetween165°Fand170°F.
*Methodofheattransmission:conduction.
*Methodofapplication:
-Addlayersoftowelingbetweenthehotpackandthepatient.
-Ifpatientmustbeplacedonpack,useadditionaltowelstominimizeexcessive
heatingoftreatmentareacausedbyweightofpatientonpackandtoprotect
bonyprominences.
-Thehotpackreachespeakheatwithinthefirst5minutesofapplication;
duringthistime,thepatientisatthegreatestriskforaburn.
*Treatmenttime:20-30minutes.

10. B)ParaffinBath:Therapeuticapplicationofliquidparaffin.Paraffinbathisa
thermostaticallycontrolledunitthatcontainsaparaffinwaxandmineraloil
mixtureina6:1or7:1ratio.Itisprimarilyappliedtosmall,irregularlyshaped
areassuchasthewrist,hand,andfoot.
*Methodofheattransmission:conduction.
*Methodofapplication:
-Glovemethod(dipandwrapwithplasticwrapandtoweling)or
-Immersionmethod(partremainsinthebathafterfinaldip).
-*Treatmenttime:15-20minutes.
*Indications:painfuljointscausedbyarthritisorotherinflammatory
conditionsinthelatesubacuteorchronicphase,jointstiffness.
*Contraindications:allergicrash,openwounds,recentsutures,skininfections.

11. C)Hydrotherapy(Whirlpool):Partialortotalimmersionbathsinwhich
thewaterisagitatedandmixedwithairtobedirectedaroundtheaffectedpart.
*Methodofheattransmission:convection.
*Methodofapplication:
-Turnonagitatorandadjusttheforce,direction,andaeration.
-Monitorpatient'sresponseandtolerancetothewhirlpool.
*Treatmenttemperature:-103°F:110°F→whirlpool.
-95°F:100°F→peripheralvasculardisease
*Treatmenttime:20minutes.
*Indications:subacuteandmusculoskeletalconditions..
*Contraindications:woundmanagement.*Precaution:GFIshouldbeinstalled.

12. Cryotherapy
*Heatremovalcan be occurred either by conduction (Cold packs, Ice pack,
Ice massage, Cold Bath), or by evaporation(Vapocoolant Sprays).
Physiological Effects of GeneralColdApplication
Increased Decreased
Blood to internal organs Pulse rate
Stroke volume Metabolic rate
Cardiac output Respiratory rate
Arterial Blood pressure Venous Blood pressure

13. IncreasedPhysiological Effects of LocalCold Application
System/Structure Mechanism
Joint stiffnessDecreased extensibility of collagen tissue
Pain ThresholdTemporary Decrease in sensory and motor nerve
conduction, Numbing effect (due to synaptic
transmission block, Releasing Endorphins
(Enkephalin and Serotonin), and Reduction of
inflammatory mediators (Prostaglandins)
Increased blood
viscosity
Adhered RBCs can decrease blood flow through
small blood vessels
Muscle strength Facilitation of alpha motor neurons
(Short duration: 1-5 min.)

14. DecreasedPhysiological Effects of LocalColdApplication
System/Structure Mechanism
Blood flow Sympathetic adrenergic activity induces
vasoconstriction of the arteries and arterioles
Muscle strength Decreased blood flow to muscles
(Long duration: > 5-10 min.)
Muscle spasm Increased firing of Golgi tendon organ and Decreased
firing of muscle spindle which decreases alpha motor
neuron activity
Spasticity Decreased muscle spindle and gamma motor neuron
activities (Long duration: 10-30 min)
Metabolism Decreased rate of cellular oxidation
Capillary PermeabilityDecreased fluid in interstitial tissue (Vasoconstriction)

15. Cryotherapy
*Application<15min.→Vasoconstriction.
*Application>15min.→Cold-InducedVasodilation(HuntingResponse).
*Adverseeffects:-Coldurticaria:erythemaoftheskinwith
whealformation,associatedwithsevereitchingduetohistamine.
-Facialflush,puffinessofeyelids,respiratoryproblems,andin
severecases,anaphylaxiswithsyncopearealsorelatedtohistaminerelease.
*Precautions:Hypertension,oversuperficialnerve,andimpairedsensation.
*Contraindications:Coldhypersensitivity(urticaria),coldintolerance,
cryoglobulinemia,peripheralvasculardisease,Raynaud'sdisease,
paroxysmalcoldhemoglobinuria,andoverregeneratingperipheralnerves.

16. Cryotherapy agents
A)Coldpacks:vinylcasingfilledwithsilicagelorsand-slurrymixture.
*Methodoftransmission:conduction.
*Methodofapplication:
-Dampenatowelwithwarmwater,wringoutexcesswater,
foldinhalfwidth-wiseandplacecoldpackontowel.
-Placepackonpatientandcoverwithdrytoweltoretardwarming.
-Thepacksaremaintainedinrefrigeratedunitat0°F-10°F.
*Treatmenttime:10-20minutes.
B)Icepacks:crushedicefoldedinmoisttowelorplacedinplastic
bagcoveredbymoisttowel.*Parameters:arethesameofcoldpacks.

17. C)Icemassage:Icecylinderformedbyfreezingwaterinapaperor
Styrofoamcup.Saltmaybeaddedtocreateacolderslushmixture.
-Alollipopstickorwoodentonguedepressormaybe
placedinwaterduringfreezingprocess.
-Duringtheapplicationoficemassage,thepatientwillusuallyexperiencethe
followingsequenceofphysiologicalresponsestages:
1)Cold2)Burning3)Aching4)Numbness.
*Methodoftransmission:conduction.
*Methodofapplication:-Applytheicemassagetoanareanolargerthan4x6
inchesinslow(2inches/second)overlappingcirclesorlongitudinalstrokes.
*Treatmenttime:5-10minutes,oruntilanalgesiaoccurs.

18. D)VapocoolantSprays:Anontoxic,nonflammablevolatile
liquidthatproducesrapidcoolingwhenappliedtotheskin.
-Vapocoolantspraysareusedprimarilytoreducemusclespasm,
desensitizingtriggerpoints.*Caution!Donotfrostskin.
*Methodoftransmission:Evaporation.
*Methodofapplication:-(Sprayandstretchmethod):
-Invertcontainer,nozzledown,hold18-24inchesfromtreatmentarea.
-Sprayat30°angleandsweepsprayovertreatmentat4inches/second.
-Themuscleshouldbepassivelystretchedbeforeandduringapplication.
-Havepatientperformactiveexerciseafterspraying.
*Treatmenttime:10-15minutes.

19. E)ContrastBath:thealternatingimmersionofabodypartinwarm
andcoldwaterproducingvascularexercisethroughactivevasodilationand
vasoconstriction.
*Methodofheattransmission:conduction.
*Methodofapplication:
-Treatmentusuallybeginsinwarmtohotwater(100°F-111°F)for4min.
-Thentransfertocoldwater(55°F-65°F)for1min.
-Continuesequenceof4:1,usuallyendinginwarmwater.
*Treatmenttime:20-30minutes.
*Indications:Anycaserequiringstimulationofperipheralcirculation.
*Contraindications:Advancedatherosclerosisandlossofsensation.

20. Q: A patient sprained the left ankle 4 days ago. The patient complains of
pain (4/10), and there is moderate swelling that is getting worse. At this
time, which intervention would be BEST to use?
A.Cold/intermittent compression combination with the limb elevated.
B.Cold whirlpool followed by massage.
C.Contrast baths followed by limb elevation.
D.Intermittent compression followed by elevation.

21. THERAPEUTIC ULTRASOUND

24. CHARACTERISTICS OF THE ULTRASOUND
WAVE AND TREATMENT PARAMETERS
1)Frequency:
*Frequencyin ultrasound (US) refers to the number of waves
delivered per second.
*Most therapeutic US units offer dual-frequency applicators
with options like 1 MHz and 3.3 MHz.
*Frequenciestypically range from 0.75to 3.3 MHz (millions of
cycles per second).
*Depthis inversely proportionalto the US frequency,Higher
frequencies(e.g., 3 MHz) are effective up to 2.5 cm deep, while
lower frequencies (e.g., 1 MHz) can penetrate up to 5 cm deep.

25. *Increasing the intensity of ultrasonic energy doesn't
necessarily result in deeper penetration; it's the frequencythat
primarily affects penetration depth.
*Tissues absorb3-MHzUSthree times faster
than 1-MHz US, leading to faster tissue heating.
N.B.
*The rate of tissue heating is related to the rate of absorption,
making 3 MHz US suitable for more superficial structures
(e.g., tendons and TMJ), while 1 MHz is used for deeper
structures (e.g., muscles).

26. Q: When using continuous ultrasound in treating the hip of an obese
patient, the GREATEST benefit might occur if the ultrasound frequency
and dosage are set at which parameters?
A.1 MHz and 1.5 watts/cm²
B.1 MHz and 0.5 watts/cm²
C.3 MHz and 1.5 watts/cm³
D.3 MHz and 0.5 watts/cm³

27. 2)Intensity:
*Intensityis defined as the amount of acoustic power, measured
in watts, per unit area of the transducer ERA, measured in square
centimeters.
*Spatial Peak Intensity (ISP) refers to the maximum
intensity delivered during the continuous delivery of US energy.
*Spatial average intensity (ISA) refers to the mean or average,
intensity delivered during pulsed delivery of US energy.
*The nonuniformityof an ultrasonic beam of energy is
represented by its beam nonuniformity ratio (BNR).
*A transducer BNRis calculated as the ratioof its spatial peak
intensity (ISP) to its spatial average intensity (ISA).

28. *Many US units have BNRs between 5 and 6,
although betterunits have BNRs of about
2 to 3.
*The areas of peak intensity can form “hot
spots”, which can easily cause tissue damage
or discomfort if an area is sonicated for too
long.
*To equally distribute these hot spots around
the treatment area and avoid burns or
discomfort, the US head must be continuously
movedin a pattern over the treatment area
throughout the period of application.

29. Tissue State Intensity required at the lesion (W/cm2)
Acute 0.1 -0.5 W/cm2
Subacute 0.5 –1 W/cm2
Chronic 1 -1.5 W/cm2
3)Mode of Delivery:
*Therapeutic CUS is delivered using the
continuousand pulsedmodes.
*Continuous mode refers to the
uninterrupted flowof acoustic energyduring
the entire treatment duration.
*Pulsed mode refers to periodic interruption of acoustic energy
characterized by ON(flow) and OFF(no flow).

30. 4)Duty cycle (DC):
*It refers to the duration, measured as a percentage(%), during
which acoustic energy is delivered and is calculated using
this formula: DC (%) = (ON/(ON + OFF)) ×100.
*The duty cycle related to the continuous mode is always 100%
*Duty cyclerelated to the pulsed mode
equals 20%:
20% = (2 ms/ (2 ms+ 8 ms)) ×100.
This duty cycle means that ultrasonic
energy is delivered for a period equivalent
to 20%of the total treatment duration.

31. 5)Treatment Duration:
*The duration of US treatment is dependent on: the surface
areaandspecific status of the treated area,and the US mode.
*For Continuous US,Don notcover an area of more than 2-3
times the ERAof the applicator head per 5 minutes of treatment.
*For Pulsed US,use the rule of 1 minute; 1 min. ×[1:2 Duty
cycle, represents pulse factor of 3 or1:4, represents pulse factor
of 5)] ×numbers of square areas will be covered by the US head.
*Move the applicator head slowly (1.5 inches per second) in
overlapping circles or longitudinalstrokes.

32. Therapeutic Effects and Indications of CUS
1)Thermal Effect:
*Higher intensity of the ultrasonic beam and continuous
emission of acoustic waves lead to more vigorous molecular
micro-vibrationand micro-frictionbetween sonated molecules.
*The increase of 1°C→ Increase metabolic rate, 2-3°C→ Reduce
muscle spasm, and 3-5°C→ Increase tissue extensibility.
2)Mechanical Effect:
*Delivery of ultrasonic energy to soft tissues induces two
mechanical effects: stable cavitation and microstreaming.

33. 3)Targeted Tissues:
*For thermomechanical effectsto occur, ultrasonic energy
must be absorbedby soft tissues.
*Attenuationreflects on the weakening of sound energy as it
propagates through a medium such as soft tissues. It reflects the
absorption.
*More dense connective tissues, such as ligamentsand tendons,
absorb US better than less dense tissues such as muscleand fat.
*Although cartilage& bonehave the highest protein (Collagen),
the problems associated with wave reflection ↓ absorption.

34. *There is an inverserelationship between absorptionand
penetration.
*Attenuationmeans that the amplitudeand intensityof US
wavesdecreaseas they travel through tissue.

35. Q: During an ultrasound (US) treatment, the patient flinches and states
that a strong ache was felt in the treatment area. What is the therapist's
BESTcourse of action?
A.Decrease the US frequency.
B.Add more transmission medium.
C.Decrease the US intensity.
D.Increase the size of the treatment area.

36. Research-Based Indications of CUS
1-Painful conditions such as Myofascial trigger points and
Back pain (Strong evidence).
2-Non-specific shoulder disorders (Moderate evidence).
3-Carpal tunnel syndrome (Strong evidence).
4-Improvingdermal wound healing (Strong evidence).
5-Calcific tendinitis (Moderate evidence).
6-Arthritis (Moderate to Strong evidence).
7-Bursitis (Moderate evidence).
8-Improving tissue extensibility (Strong evidence).

37. Direct Contact
method
Indirect Gel Pad
Contact method
Noncontact method
(Immersion Technique)

38. Precautions for CUS:
1-Plastic or cemented implants—moderate evidence for damage
to these.
2-Spinal cord and superficial or regenerating nerves—poor
evidence for this but still considered a precaution.
3-Implanted cardiac pacemaker or breast implants electronics—
unsure if damage to the device could occur because of either
heating or vibration.
4-Impaired sensation—nerve damage, so no sensory feedback
about excessive warmth or burning.
5-Impaired cognition—no feedback about excessive warmth.

39. Contraindications for CUS:
1-Pregnancy—over the abdomen, low back, and pelvis
2-Active bone growth at the epiphysis
3-Cancer—over a known or suspected area of malignancy
4-Tuberculosis infection—infected tissue, particularly
that under tension (swelling/abscesses)
5-Hemorrhagic conditions—over an area of active bleeding;
N.B. CUS can be used for areas of hematoma and hemophilia.
6-Thermal-sensitive reproductive organs like testes.
7-Eyes
8-Anterior neck—particularly over the carotid sinus.

40. *Phonophoresisis the application of the USto enhance the
absorption of topical agents through the skin.
*Topical Drugs can be absorbed with continuousor pulsedUS,
however, pulsed US with a 20% duty cycle and under 0.5-0.75
W/cm2for 5-10 minutes is the recommendedparameter for
phonophoresis.
*Most commonly, hydrocortisone and analgesics(such as
salicylatesand lidocaine) are administered in a gel formula
rather thancreamsas a coupling medium with phonophoresis.

41. EXTRACORPOREAL SHOCKWAVE THERAPY

42. Focused ShockwaveRadial Shockwave

43. *It is more accurate for r-ESWTdevices to use barsrather than
mJ/mm2 when representing the pressure level (EFD).
*Classification of Shockwave Intensity (EFD):
-LowEnergy Shockwave is below 0.08 mJ/mm2.
-Medium Energy Shockwave is between 0.08 -0.28 mJ/mm2.
-High Energy Shockwave is above 0.28 mJ/mm2.
*Intensity of Radial Shockwave:
-Less than 1.5 bar for activation of tissue healing.
-Between 1.5 -2 barsfor pain, chronic inflammation, muscle
spasm, trigger points, and edema reduction.
-Above 2.5 bars for elimination or reabsorptionof calcifications.

44. -It is recommended to start with higher frequencies and gradually
decreaseit during treatment.
-For instance, a treatment plan may involve 200 shocks at 16 Hz,
followed by 200 at 14 Hz, and then 200 at 12 Hz, ultimately aiming for a
target frequencyof 10 Hz with a total of 2000 shocks.
-Shock number usually between 1500and 2000in a treatment session.
-Most clinical research has used between 3 –5 sessions at low energy
levels, suggesting up to 7 may be needed in the more refractory lesions.
-Treatment sessions are mostly delivered at 1 x weekly intervals.
-Apply treatment: Ensure adequate monitoring.
-Post-treatment inspection: Inspect the treated skin area for any light
bruising or swelling. Reassure the patient that these are normal side
effectsthat will disappear within a few hours or days.

45. Physiological
and
Therapeutic
Effects
of ESWT

46. Research-Based Indications of ESWT
1-Shoulder, Elbow, Achilles, and Patellar chronic
tendinopathies.
2-Chronic plantar fasciitis and Calcaneal Spurs.
3-Calcific tendonitis of the rotator cuff in the shoulder.
4-Chronic foot ulcers, either diabetic or nondiabetic.
5-Osteoarthritis of the knees.
6-Nonunion and delayed-union bone fracture.
7-Avascular Necrosis of the femoral head.
*Overall conditions, the strength of evidence is moderate.

47. Contraindications for ESWT:
1-Bleeding conditions—severe bleeding.
2-Pacemakers.
3-Medications that prolong blood clotting.
4-Over major blood vessels and nerves, and Joint replacements.
5-Pregnancy: over uterus—disrupts fetal development.
6-Acute injuries—increase the inflammatory process.
7-Active bone growth at the epiphysis—alters normal growth.
8-Cancer—over a known or suspected area of malignancy.
9-Over gas-filled tissues such as lungsand intestine—severe
tissue damage.

48. Precautions While Using ESWT:
*Some side effects can occur after treatment, includingtransient
pain, hematoma, petechiae, and local soft tissue swelling.
*Avoidthe use of anti-inflammatory drugs immediately
after ESWTsessions because it may disturb the desired effect of
ESWT, the conversion of chronic inflammation into acute one.
*It is allowed to use some painkillers that have noanti-
inflammatory effectslike Paracetamolto relieve the transient
pain after ESWT.

49. SHORTWAVE DIATHERMY
*SWD is the use of shortwave electromagnetic energyfor
heating deep soft tissues such as musclesand joints.
*The resistanceoffered by soft tissues to the passage of
shortwaveelectromagnetic energy causes them to heat up.
*The most common diathermy device in use today
delivers 27.12 MHzfrequency waves from the short
wavelength radio wave section of the electromagnetic
spectrum.

51. 1-Capacitive Applicators: The capacitive method of SWD
(also known as the electric field method ) uses an
applicator system that requires that the patient’s
tissues become part of a capacitor.
*A capacitoris a device that can storeelectrical
charge and consists of two conducting objects
placed near each other and usually separated by a
dielectric.
*The capacitive electrodes cause an oscillating electric current
to flow through the body tissues between the electrodes.
*Resistanceto current flow in the tissue results in tissue heating.
Types of Shortwave Diathermy

52. *Capacitive SWD devices have adjustable arms with metal
plates (electrodes) at their ends.
*Most capacitive SWD plates have a glass or plastic
guardsurrounding each metal plate to prevent contact
between the electrode and the patient’s skin.
*A severe electrical burn may occur if either the
therapist’s or the patient’s skin contacts the bare
metal plate of the diathermy device.
*A single layer of terrycloth toweling should be placed between
the plate guards and the patient’s skin to prevent
the concentration of the electric field on
perspirationthat may accumulate on the skin.

53. *As the plate-to-skin distance increases, heat perception
decreases.
*Capacitiveheats efficiently fat, Collagentissues such as skin.
1)Contraplanar arrangement: the plates are
placed on each side of the body part so that the
body part creates a biological capacitor.
2) Coplanar arrangement: it requires positioning
the plates parallel on the same body surface.

54. 2-Inductive Applicators: The inductive method of SWD
(also known as the magnetic field method ) requires an inductive
applicator that creates an oscillating magnetic field that induces
“eddy” currents in body tissues.
*It is suitable for the highest electrolyte content, such as skeletal
muscleand Synovial tissues.
1)Drum applicators:
A) Amonode: is a drum used to treat a single-body
surface.
B) A diplode: is a hinged drum that allows one or
more body part surfacesto be treated simultaneously.

55. 2)An induction sleeve: Sleeves are designed to fit around
a body part, such as the elbowand forearm, providing a
circumferential treatment effect.
-The advantages of diathermy sleeves include their portability
and ease of application.
-A disadvantage is their heating ability is limited to moderate
tissue temperatureincreases.
*Key Point* The electromagnetic waves
produced by diathermy devices will not
cause depolarization of nerves or muscles. They are nonionizing
and will not cause cell mutations.

56. Physiological effects of diathermy
A) Thermal effects in continuousmode:
-Increased tissue temperature both deep and superficial
-Increased soft tissue extensibility
-Increased Beta nerve conduction increased pain threshold,
-Vasodilation
B) Non-thermal effects in pulsedmode:
-Increased microvascular perfusion
-Increased local tissue oxygenation
-Increased cell growth (Healing of wounds and Diabetic ulcers)

57. Indications and goals of SWD:
1-Increased joint ROM as in joint contractures.
2-Improved rate of edema dispersion.
3-Encourages absorption of hematoma.
4-Pain management.
5-Wound control and soft tissue healing.
6-Resolution of acute and chronic infections.
7-Stimulation of osteogenesis.

58. Contraindications for SWD:
1-Pacemakers or insulin pump.
2-Pregnancy of the patient.
3-Open epiphysis.
4-Malignancy.
5-Active tuberculosis.
6-Over sensitive tissues such as eyes and tests.
7-Metal implants and Jewelry.
8-Over metal loops that secure plates or rods

59. Q: A therapist has elected to use continuous inductive coil short wave
diathermy (SWD) as one of the interventions in managing hip pain. Use
of other thermal or electrical modalities were either ineffective or
contraindicated. Which patient would be a candidate for use of short
wave diathermy?
A.A morbidly obese patient.
B.A patient with Type 1 diabetes who uses an insulin pump.
C.An 11 year-old boy with a slipped capital femoral epiphysis.
D.A patient with ankylosing spondylitis on high doses of NSAIDS and
DMARDS

60. Precautions for SWD:
1-Use of diathermy near other electronic or magnetic equipment;
e.g., computers, US, and cell phones.
2-Very obese patients, since fat may be heated excessively.
3-Patients or other nearby personnel using metal bearing IUD.
4-Pregnancy of therapist or other health care providers.
Treatment considerations:
*Treatment time is 20 minutes for thermaland 30-60 minutes
for non-thermal.
*It is considered unwise to operate two SWD/ PSWTwithout
maintaining a separation of at least 3 meters.

62. LOW-LEVEL LASER THERAPY

66. Physiological
Effect
of
Low-Level
Laser
Therapy
(LLLT)

67. Parametersof LLLT
1. Wavelength:
-Helium-neonlaser 632 nm for superficial penetration (0.5-2cm)
-Gallium arsenidelaser 905 nm for deeppenetration (2-10cm)
2. Frequency:
-200 Hz to 10,000 Hz.
-For healing less than 1000HZ and for pain relief more than 1000HZ.
3. Power output:
-The power output of the machine is expressed usually inmilliwatts.
-Powerisfrom 2 mw to 500 mw to vary the energy.

68. 4.TotalEnergy:
-This is given in joules(J)
-It is expressed the energy of irradiation for the total treatment
J = 1 W×sec
Ex:a 30 mW device applied for 1 min.
0.03×60 = 1.8 J
5.Energy density:
-It’sthe best method of specifying dosage and is given injoules per unit
area(J/cm2).
*N.B.
-ENERGY DENSITYper TREATMENT SESSION should generally fall
in the range of 0.1 -12.0 J/cm2 though there are some recommendations
that go up to 30 J/cm2.

70. 6. Mode:
-Pulsedin acute conditions and continuousin chronic.
-Pulse ratio is 10%,20%up to 100%.
-Helium-neonlasers are usually in continuousmode.
-Gallium arsenidelasersare usually in pulsedmode.
*Delivery technique:
I-Contact technique. II-Non-contact technique.

71. Research-Based Indications of LLLT
1-Dermalwounds.
2-Tendinopathies.
3-Myofascial/trigger point pain.
4-Rheumatoid arthritis.
5-Mixed painful musculoskeletal conditions.
6-Osteoarthritis.
7-Herpes/postherpetic pain.
8-Neck/lower back pain.
9-Temporomandibular disorders.
10-Carpal tunnel syndrome.

72. Contraindications for LLLT:
1-Over the eye—damage to the retina.
2-Over a malignant lesion—further spread of lesion.
3-Over the abdominal and pelvic area of a pregnant woman—
interference with normal development and growth of the fetus.
4-Over a hemorrhagic area—exacerbating the condition by
laser-induced vasodilation.
5-Over the thyroid gland—interfering with normal function of
the thyroid gland.
6-In patients with epilepsy—inducing an epileptic seizure.
N.B. Metal and plastic implants, as well as pacemakers, are
not contraindicated and can be used safely.

73. Precautions for LLLT:
1-Over bruised muscle—the risk of enhancing bruising.
2-Over testicular region—risk of affecting fertility.
3-Over sympathetic ganglia, vagus nerve, and cardiac region in
patients with heart disease—risk of adverse heart effects.
4-Over the bone epiphyseal region of growing children—the risk
of affecting bone growth.
5-Over an infected area—the risk of stimulating or inhibiting
bacterial activity.
*Before treatment with LLLT, bothpatients and practitioners
must wear protective glasses or goggles, which filter the
wavelength range emitted by the laser device during therapy.

74. MECHANICAL SPINAL TRACTION

76. *Traction force to the cervical spineshould NOTexceed
13.5 kg (30 lb).
*For lower cervical problems, 25-35°neck flexion is required,
while for upper cervical problems, only 0-5°is sufficient.
Positional traction to stretch and distract the left lumbar area

77. Q: A therapist has decided to use mechanical lumbar traction on a patient
with posterior herniated nucleus pulpous at L2-3. If tolerated by the
patient, what is the BEST positioning for this treatment?
A.Prone, with no pillow under the hips or abdomen.
B.Prone, with a pillow under the hips and abdomen.
C.Supine, with the hips and knees flexed to 45 degrees.
D.Supine, with hips and knees flexed to 90 degrees.

78. -Claustrophobia, hernia, vascular compromise,
pregnancy, and impaired cognition.
-Any disease or condition that can compromise the
structure of the spine, such as: osteoporosis, tumor,
infection, rheumatoid arthritis, or protracted steroid use
-TMJ; problems with halter use
-Disc extrusion; medial disc protrusion;
*Precautions for Mechanical Traction:

80. -Acute strains, sprains, and inflammation
-Spondylolisthesis, fractures, postop spinal surgery,
spinal joint instability,and spinal cord compression
-Hypertension
-Increased peripheralization of pain, or numbness
-Decreased reflex response and myotomal strength
*Contraindications for Mechanical Traction:

81. INTERMITTENT PNEUMATIC COMPRESSION
*Pneumatic device that applies
external pressure to an
extremity through an inflatable
appliance(sleeve).
*Coldcan be applied
simultaneously with
intermittent compression in
which a coolant(50°F-77°F)is
pumped through an inflatable
sleeve.

82. *Precautions for Intermittent Compression:
-Impaired Sensation.
-Uncontrolled hypertension
-Over an area with a superficial nerve (Fibular nerve)
-Malignancy
*Chronic stable DVT→ High Resting Pressure and Low Work Pressure
*For Edema &Ulcers→ Low Resting Pressure and High Work Pressure

83. -Acute inflammation, trauma, or fracture
-Acute deep venous thrombosis (DVT) and
thrombophlebitis
-Obstructed lymph or venous return
-Arterial insufficiency andarterial revascularization
-Acute pulmonary edema
-Diminished sensation
-Edema with cardiac orrenal impairment
-Hypoproteinemia (<2 g/dL)
*Contraindications for Intermittent Compression:

84. *MethodofIntermittentCompressionapplication:
-Checkpatient'sbloodpressure.
-Settheinflationanddeflationratioto~3:1.Generally,foredemareduction,
45-90secondson/15-30secondsoff.-Forshapingaresiduallimba4:1ratio.
-Turnthepoweronandslowlyincreasethepressuretothedesiredlevel.
-Neverexceedthepatient'sdiastolicbloodpressure.thepressureshouldfall
betweenthediastolicandsystolicpressure
-Tingling,pulse,orpainshouldnotbefeltbythepatientduringthetreatment.
*Treatmenttime:-Lymphedema:2hoursprogressingto3-hourdaily
-Traumaticedema:2hoursdaily
-Venousulcers:2.5hoursthreetimes/weekprogressingto2hoursdaily
-Residuallimbedema:1hourprogressingtothreesessionsof1-hourdaily

85. CONTINUOUS PASSIVE MOTION
*ItisUninterruptedpassivemotionofthejointthroughacontrolledROM.A
mechanicaldeviceprovidescontinuousmovementforextendedperiodsoftime.
*PhysiologicaleffectsofCPM:
-Acceleraterateofinter-articularcartilageregenerationandimproveitsnutrition.
-Tendonandligamenthealing.
-Decreaseedemaandjointeffusion.
-MinimizecontracturesandPreventadhesions.
-Decreasepostoperativepain.
-Increasesynovialfluidlubricationofthejoint.
*ItiscommontouseitafterACLreconstructivesurgery.

86. TILT TABLE
*Mechanicalorelectricaltabledesignedtoelevatepatientfromhorizontal(0°)to
vertical(90°)positioninacontrolled,incrementalmanner.
*Physiologicaleffectsoftilttable:
-Stimulateposturalreflexestocounteractorthostatichypotension.
-Facilitateposturaldrainage.
-Gradualloadingofoneorbothlowerextremities.
-Beginactiveheadortrunkcontrol.
-Providepositioningforstretchofhipandkneeflexors,andankleplantarflexors.
*Indications:Prolongedbedrest,SCI,traumaticbraininjury,orthostatic
hypotension,andspasticity.*Treatmentduration:30-60min.1or2/daily.
*Begininsupineposition,Abdominalbinder&longelasticstockingsmaybeused.

87. Subsensory
No nerve fiber activation
No sensory awareness
Sensory
Nonnoxiousparesthesia
Tingling, prickling, or pins and needles
CutaneousA-betanerve fiber activation
Motor
Strongparesthesia
Muscle contraction
A-alphanerve fiber activation
Noxious
Strong, uncomfortableparesthesia
Strong muscle contraction
Sharp or burning pain sensation
A-deltaandC fiberactivation
Levels of Electrical Stimulation

89. *Iontophoresis:is a technique which uses an electric currentto delivera
medicineor other chemical through the skin. In popularterms it is sometimes
called "an injection without the needle".
-Negative ionized drugsare repelled by the cathode
While, positive ionized drugsare repelled by the anode.
Current TypeDC
Current
Amplitude
1.0 -4.0 mA
Treatment
Duration
20 -40 minutes
Total Current
delivered
40-80mA/min
*Optimal Current
Variables used in
Iontophoresis

92. HighTENS
(Conventional )
Low TENS
(Acupuncture)
Brief
IntenseTENS
Pulseamplitude
(Intensity)
•Low (Sensory)
•Increase intensity toproduce a
strong butcomfortable
tinglingsensation
•High (motor)
•Increase intensity to produce a
strong but comfortablemuscle twitch
•High (Noxious)
•Increase intensity to
producean
uncomfortable
tinglingsensation
Pulse Frequency (Hz) High (50-100 Hz) Low (1-5Hz) High (100Hz)
Pulse duration 50-100μsec 150-300 μsec 50-250μsec
Electrode placement
Site of pain or over main nerve
bundle
proximal to pain
Over muscle or motor point
•Site of pain orover
main nervebundle
•Motor, trigger or
acupuncture points.
Treatment duration As needed(20 -60 minutes) 15-30 minutes Lessthan15minutes
Onset of relief <10 minutes 20-40 minutes < 15 minutes
Mechanism of pain
relief
•Stimulate large diameter
A-Betaafferent nerve fibers
•(Gatecontrol theory)
•Stimulate bothsmall cutaneous
A-Deltaafferent and motor nerve
fibers
• (Endogenous-Opioid mechanism )
•Stimulation
ofsmallcutaneous A-
Deltaafferent nerve
fibers

93. *Brief intense TENS: this mode is used to provide rapid-onset, short-term
pain relief (30-60 min.)during painful procedures (Post surgical pain, wound
debridement, deep friction massage, joint mobilization, or passive stretching).
*Burst-mode (pulse trains) TENS: combines characteristics of both high and low
frequency TENS. Stimulation of endogenous opiates. Frequency: 50-100 Hz
delivered in bursts of 1-4 Hz. Long-lasting analgesic effect (Hours).
*Hyperstimulation (point stimulation) TENS: use of a small probe to locate and
noxiously stimulate acupunctureor trigger points. Similar to acupuncture-like
TENS.

94. Q: A patient complains of pain (7/10) in the shoulder region secondary to
acute Subdeltoid bursitis. As part of the plan of care during the acute
phase, the therapist elects to use conventional TENS. Which of the
following BEST identifies the modulating properties of this biophysical
device?
A.Stimulation of endorphins.
B.Gate control mechanisms.
C.Descending inhibition.
D.Ascending facilitation.

95. HIGH VOLTAGE PULSED GALVANIC CURRENT
*It is a monophasic(Directcurrent), twin-peakedpulses with short durations.
*Wound healing parameters: (1) Amplitude: comfortable tingling sensation,
paresthesia, no muscle response.
(2) Frequency: 50-200 Hz.
(3) Pulse duration: 20-200 μsec.
(4) Mode: continuous.
(5) Duration of treatment: 20-60 min.
(6) For bactericidaleffect: Begin with Cathode(Negative electrode) at the
wound area or around it for 3 days then change the polarity to the positive.

97. Q: A patient with a 2-inch stage II decubitus ulcer over the left lateral
malleolus is referred for physical therapy. The therapist notes a greenish,
pungent exudate at the wound site. The therapist decides to use electrical
stimulation. What is the BEST choice of polarity and electrode
placement?
A.Cathode placed in the wound.
B.Cathode placed proximal to wound.
C.Anode placed in the wound.
D.Anode placed proximal to wound.

98. *Two channels(and four electrodes) are used to deliver IFC:
1.One channelhas a set frequency, which is called
thecarrier frequencye.g. 4000 Hz.
2.The other channelhas an adjustable frequency
(e.g. 3900), which is used to produce abeat frequency
(e.g. 100Hz), the difference between the two frequencies.
INTERFERENTIAL CURRENT

99. *There are two types of vectors, static and dynamic:
1.Astatic vectordoesnot movebut stays centered where the
currents cross(treats localized pain)
2.Adynamic vectormovesthroughout the treatment field
between the four electrodes. This is done by altering the beat
frequency (by changing the second current’s frequency), a
feature known assweepor scan(treat poorly defined pain).
*Durationof treatment: 20-30 min.

100. Q: A patient strained the lower back muscles 3 weeks ago, and now
complains of pain (6/10). Upon examination. the therapist identifies
bilateral muscle spasm from T10-1.4. The therapist elects to apply
interferential current to help reduce pain and spasm. What is the BEST
electrode configuration in this case?
A.Four electrodes, with current flow perpendicular to the spinal column.
B.Two electrodes, with current flow perpendicular to the spinal column.
C.Four electrodes, with current flow diagonal to the spinal column.
D.Two electrodes, with current flow parallel to the spinal column.

101. RUSSIAN CURRENT (RC)
Characteristics
Medium-frequencypolyphasicalternating sinusoidal
interruptedcurrent
Carrier frequency
2,500 Hz
Burst modulatedThe bursts are delivered at 50 burstsper second with a burst duration of 10
msec and aninterburstinterval of 10 msec
Duration
phase duration 200μsec
cycle duration 400μsec
Dutycycle
50%
Protocol: 10/50/10 (10-second contraction time, 50-second off-time, 10
repetitions).
RUSSIAN CURRENT

103. FUNCTIONAL ELECTRICAL STIMULATION
A)Shouldersubluxation:-Patientswithcerebrovascularaccident(CVA)may
initiallyexhibitweaknessofthesupraspinatusandposteriordeltoid.
-FEScharacteristics:(1)Waveform:asymmetricalbiphasicsquare.
(2)Current:interruptedpulsatilecurrent.
(3)Electrodeplacement:Bipolar:Electrodeson
supraspinatusandposteriordeltoid.
(4)Amplitude:tetanicmusclecontractiontopatient'stolerance.
(5)Pulserate:12-25Hz.
(6)Durationoftreatment:15-30minutes.Threetimesdaily,upto6-7hours.
(7)On/offratio:1:3(2sec:6sec)progressingto12:1(24sec:2sec).

104. B)Dorsiflexionassistingait:-Patientswithhemiplegiasometimes
exhibitparalyzeddorsiflexorsandevertors.
-FEScharacteristics:(1)Waveform:asymmetricalbiphasicsquare.
(2)Current:interruptedbyfootswitch.
(3)Electrodeplacement:Bipolar:Peroneal(fibularnerve)
nearheadoffibulaortibialisanteriormuscle.
(4)Amplitude:tetanicmusclecontraction.
(5)Pulserate:30-300Hz.
(6)Pulseduration:20-250μsec.
(7)Treatmentmode:Heelswitchcontainspressure-sensitive
contactthatstopsstimulationduringstanceandactivatesduringswing.

105. Types of Electrodes
1)Carbon -Impregnated Rubber Electrodes-degrade
over timeand become non-uniform with "hot spots", many
shapes and sizes, rinse and dry after each useandreplaced
every 12 monthsto ensure conductivity.
2)Self-Adhering or Single use Electrodes-flexible
conductors, convenientapplication, no strappingor tapingto
keep in place, used most frequently these days.
3)Vaginal or Rectal Electrodes-These electrodes are
used vaginallyor rectallyto stimulate or sense the pelvic
floor muscles. Disinfectionis critical.

106. MonopolarTechnique
*Active electrodeover target area (Smaller)
*Dispersive electrodeanotherremotesite (Larger)
*Used with wounds, Iontophoresis, and Edema.
Bipolar Technique
*Two active electrodesplaced over target area (Equal in size)
*Used for muscle weakness, Neuromuscular facilitationand spasms.
Quadripolar Technique
*Two electrodesfromtwo separate stimulating channelspositioned
so, the currentsintersect as criss-cross Interferential Current.
Techniques

108. EMG BIOFEEDBACK
*Electronicinstrumentusedtomeasuremotorunitactionpotentials
(MUAP)generatedbyactivemuscles.Thesignalsaredetected,amplified,and
convertedintoaudiovisualsignalsthatareusedtoreinforcevoluntarycontrol.
*Motorunit:thefunctionalunitoftheneuromuscularsystemthatconsistsof
theanteriorhorncell,itsaxon,theneuromuscularjunction,andallthemuscle
fibersinnervatedbytheaxon.
*Motorunitactionpotentials(MUAP)aremeasuredinmicrovolts(UV).
*RecordingElectrodes:
A)Surfaceelectrodes:-Globaldetection:signalsfrommorethanonemuscle.
-Detectionfrommostlysuperficialmuscles.-Advantages:easytoapply
-Disadvantages:detectionfrommostlysuperficialgroupedmuscles.

109. B)Needleelectrodes:-Localdetection:signalsfromspecificmuscle.
-UsedmainlyforEMGdiagnosisratherthanBiofeedback.
*Electrodeplacement:-Bipolartechnique:twoactive(positiveandnegative)
andonereference(ground)electrode.
-Thereferenceelectrodemaybeplacedbetweenoradjacenttoactive
electrodes.-Activeelectrodesareplacedonornearmotorpointoftargeted
muscleormusclegroup1-5cmapart
-Activeelectrodesareplacedfurtherapart;yieldslargesignals,detectionfrom
morethanonemuscle.
1)Forweakmuscles:Beginwithelectrodeswidelyspacedandbiofeedback
instrumentsensitivityhigh,toincreasedetection.Muscleisassessedinan
isometriccontraction(holdfor6-10Sec.).

110. -As patient's motor recruitment ability improves, decrease the sensitivity,
making it more difficult to produce an audiovisual signal.
-Use facilitationtechniques (tapping, and vibration) to encourage
motor unit recruitment, if necessary.
-Treatment sessions may be from
5-10 minutes to ≥ 30 minutes.
2) For spasmed or hypertonic muscles:-Begin with electrodes closely spaced
and biofeedback instrument sensitivity low to minimize cross-talk.
-Instruct patient to relax, using deep breathing or visual imagery to help lower the
audiovisual signal.
-As patient's motor control progress,increase the sensitivity.
-Treatment sessions may be from 5-10 minutes to ≥ 30 minutes.
*Criteria for Biofeedback training: Good vision, hearing, concentration,
comprehension, motor planning skills, and NOprofound sensory loss.
BeginningDistance between active electrodesSensitivity
Weak M ↑ ↑
Spastic M ↓ ↓

111. Q: A patient is referred for outpatient care after a tendon transfer of the
extensor carpi radialis longus. The muscle strength tests poor (2/5) in
spite of previous intensive therapy. The therapist elects to apply
biofeedback to assist in progressively increasing active motor
recruitment. What is the BEST choice for the initial EMG protocol?
A. High-detection sensitivity with recording electrodes placed far apart.
B. Low-detection sensitivity with recording electrodes placed close
together.
C. High-detection sensitivity with recording electrodes placed close
together.
D. Low-detection sensitivity with recording electrodes placed far apart.