PHYSICAL THERAPY AND PHYSIOTHERAPY MODALITIES S1, INTRODUCTION Modern electrotherapy practice needs to be evidence based and used appropriately. Used at the right place, at the right time for the right reason, it has a phenomenal capacity to be effective. IN COMBINATION WITH EXERCISE IT GOES GREATLY (from atrophy I can have a muscle regeneration in 6 months). Used unwisely, it will either do no good at all or possibly make matters worse as would be true for any other therapy. The skill of the practitioner using electrotherapy is to make the appropriate clinical decision as to which modality to use and when, and to use the best available evidence when making that decision. He has to know what modalities and what time is beneficial for each patient.

Electrotherapy in this context is used in the widest sense. Strictly speaking some modalities (Ultrasound and Laser for example) do not strictly fall into an electrotherapy grouping (in that they do not deliver an electric current), which is why some authorities prefer the term Electro Physical Agents (EPAs) which would encompass a wider range. WHAT IS ELECTROTHERAPY? A simple, but effective clinical decision-making model (represented in the adjacent diagram) can be utilised. All electrotherapy modalities (with the exception of biofeedback) involve the introduction of some physical energy into a biologic system. This energy brings about one or more physiological changes, which are used for therapeutic benefit. Clinically, it is probably more useful to work the MODEL IN REVERSE - determine first the nature of the problem to be addressed (for example, US is good for frozen shoulder and for any other cartilage changes) .Then establish the physiological changes that need to take place in order to achieve these effects. The DOSAGE is very important; the frequency and the intensity has to change if the pz is chronicle or acute. Lastly, the modality that is most able to bring about the changes in the tissue(s) concerned should be a relatively straightforward decision. In the clinical environment, there are two additional jobs to do: firstly to select the most appropriate dose of the therapy and then lastly to apply the treatment. Generally speaking, the delivery of the therapy is relatively straightforward. The dose selection however is critical in that not only are the effects of the treatment modality dependent, but they appearing to be dose dependent as well. In other words, it is important to select the most appropriate modality based on the available evidence, but also to deliver it at the most effective known dose. The electrical activity of the body has been used for a long

time for both

diagnostic and monitoring purposes in medicine, largely in connection with the excitable tissues. Examples include ECG, EMG, EEG. More recent developments have begun to look at the tissues that were not regarded as excitable, but in which, endogenous electrical activity has been demonstrated. GENERAL MODEL IN ET The delivery of energy to the tissues (in this case a form of electric current) will bring about physiological changes in the tissues (nerve stimulation) and thereby achieve therapeutic benefit. The critical issues are to set the

machine in such as way as to stimulate the target nerves as effectively and as efficiently as possible. Stimulation of sensory nerves will achieve a sensory outcome; similarly, stimulation of motor nerves will bring about a motor effect. Clearly it is not

possible to ONLY stimulate one type of nerve or another, BUT it is possible to primarily have an effect on a nerve type by setting appropriate parameters on the stimulation device. Some electrotherapy machines in this area are specific and dedicated to a particular task (e.g. TENS) whilst others offer numerous different stimulation modes, and a selection can be made typically from a menu system.

sensory level stimulation: I pick on pz's arm the first time to make him understand what he could feel.

motor effect: I can see the contraction of the muscle, according to where I put the stimulation

There is a developing range of research that is considering the effect of electrical stimulation intervention of physiological processes other than nerve stimulation (e.g. micro current therapy to enhance tissue repair) but this introduction will be confined to the nerve stimulation principles. Action potential is forced or stimulated someway along the length of the nerve. The electrical current (or pulse of electricity) is the external stimulus that initiates the action potential. Assuming that it is sufficiently large to overcome the threshold then the action potential that results from the electrical stimulation is not any different from one that is initiated naturally the initiation comes from outside the body, but once initiated, the outcome is the same. TYPES OF ELECTRICAL STIMULATION There is little doubt that this is one area of electrotherapy where there appears to be a proliferation of machines or various and diverse properties. New machines seem to come out every couple of months and there is a

degree of confusion with regards what they do, what they are best used for and how effective they are at doing that job. NB. I should always look at the research to understand which is the best technique that I can use for the pz that I have: everyone use TENS that affect skin level, cutaneous level and nerve level, but our body learn to adapt to this, it makes an evolution. After had used TENS for 6 weeks in 6 months, I have to change the intensity to have the same result, to have the same level stimulation. Some manufacturers try and name the intervention modality the same as the machine so you end up with Pulsed XXX Therapy. In reality, the most appropriate thing to do is to consider the various TYPES of simulation, and to put machines into the appropriate category / categories (in that some machines offer several different forms of stimulation). How to explain to the patient? for ex. for IFC: electric current is sent into the body; we generally use electricity to help muscles to move more. I place the patches in some areas to search for the twitch of the muscle, depending what I need, or a little bit of twinkle (little massage to the muscle). Anyway effects come from outside the body, which produce an internal stimulation, that helps to increase the work of nerves and muscles. TENS (Transcutaneous electrical nerve stimulation) Sensory nerve stimulation used primarily for pain relief INTERFERENTIAL THERAPY IFT / IFC

A flexible stimulation modality which can be bent to mimic other stimulation modes.

Used for pain relief, increased circulation, and muscle stimulation Neuromuscular electrical stimulation NMES the goal of treatment is to elicit a strong muscle contraction through

stimulation of the motor nerve. Can be used to slow disuse atrophy in innervated muscle, to gain

muscle strength and bulk pattern should be distal to the muscle or the area that I want to affect

IONTOPHORESIS Ions in solution are transferred through the intact skin via an electrical potential (like charges are repelled). Most commonly used to suppress inflammation and pain though has other potential uses INTERRUPTED DIRECT CURRENT IDC Direct stimulation of denervated muscle: electrical stimulation does not bring about reinnervation, but is thought to maintain the contractile proteins in the muscle whilst awaiting reinnervation. Microcurrent Therapy MCT

Delivery of very small (literally several millions of an amp) continuous or pulsed current. Shown to be effective is in treatment of slow-healing wounds and fractures. Some developing applications in soft tissue injury and healing. Also potential as trigger point /acupuncture point stimulation. The current is applied sub threshold in that the patient cannot feel the stimulation and is therefore different from all others in the list as its primary mode of action is not thought to be nerve mediated. RUSSIAN STIMULATION An alternating current with a carrier frequency of 2500Hz (described my many therapists as 'medium frequency) is 'chopped' into short bursts at 50Hz with a 50% duty cycle. In this way, the motor nerves re able to respond and the discomfort associated with the therapy is diminished (as with Interferential Therapy) by virtue of the medium frequency carrier. S2 TENS TENS is a method of electrical stimulation that primarily aims to provide a degree of symptomatic pain relief by exciting sensory nerves and thereby stimulating either the pain gate mechanism and/or the opioid system The different methods of applying TENS relate to these different physiological mechanisms. The effectiveness of TENS varies with the clinical pain being treated, but research would suggest that when used well it provides significantly greater pain relief than a placebo intervention. TENS is most commonly delivered from small, hand held, battery powered devices. They can be purchased 'over the counter' in many (but not all) countries. In some locations, they need to be 'prescribed' by a therapist, doctor or other healthcare practitioner. TENS as a treatment technique is non invasive and has few side effects when compared with drug therapy. NB. Any electrotherapy around the abdominal area is a contraindication. The most common complaint is an allergic type skin reaction (about 2-3% of patients) and this is almost always due to the material of the electrodes, the conductive gel or the tape employed to hold the electrodes in place. The pads don't last very long; this is why people generally use gel or tape to hold the electrodes in their place. Most TENS applications are now made using self adhesive, pre gelled electrodes which have several advantages including reduced cross infection risk, ease of application, lower allergy incidence rates and lower overall cost.

Digital TENS machines are becoming more widely available and extra features (like automated frequency sweeps and more complex stimulation patterns) are emerging, though there remains little clinical evidence for enhanced efficacy at the present time. Some of these devices do offer pre-programmed and/or automated treatment settings. Before attempting to describe how TENS can be employed to achieve pain relief, the main treatment variables, which are available on modern machines, will be outlined. The location of these controls on a

typical (analogue) TENS machine is illustrated in the diagram below. The CURRENT INTENSITY (A) (STRENGTH) will typically be in the range of 0 - 80 mA, though some machines may provide outputs up to 100mA. Although this is a small current, it is sufficient because the primary target for the

therapy is the sensory nerve, and so long as sufficient current is passed through the tissues to depolarise these nerves, the modality can be

effective. The machine will deliver discrete pulses of electrical energy, and the rate of delivery of these pulses (the PULSE RATE or FREQUENCY (B) will normally be variable from about 1 or 2 pulses per second (pps) up to 200 or 250 pps (sometimes the term Hertz or Hz is used here), depending on the pain. To be clinically effective, it is suggested that TENS machine should cover a range from about 2 150 pps (or Hz). In addition to the stimulation rate, the DURATION (OR WIDTH) OF EACH PULSE (C) (how fast-slow it is) may be varied from about 40 to 250 microseconds (a micro second is a millionth of a second). Recent evidence would suggest that this is possibly a less important control that the intensity or the frequency and the most effective setting in the clinical environment is probably around 200s. The reason that such short duration pulses can be used to achieve these effects is that the targets are the sensory nerves which tend to have relatively low thresholds (i.e. they are quite easy to excite) and that they will respond to a rapid change of electrical state. There is generally no need to apply a prolonged pulse in order to force a sensory nerve to depolarise, therefore stimulation for less than a millisecond is sufficient. In addition, most modern machines will offer a BURST MODE (D) in which the pulses will be allowed out in bursts or trains, usually at a rate of 2 - 3 bursts per second; it elevates the intensity little bit more. Finally, a MODULATION MODE (E) may be available which employs a method of making the pulse output less regular and therefore minimising the accommodation effects, which are often encountered with this type of stimulation. It's not very good for diffuse pain, is better for local pain. Both the burst and modulation modes will be discussed in more detail in the following sections. ( N=normal, M= modulated). Most machines offer a DUAL CHANNEL OUTPUT - i.e. two pairs of electrodes can be used simultaneously. In some circumstances this can be a distinct advantage, though it is interesting that most patients and therapists tend to use just a single channel application. Widespread and diffuse pain presentations can be usefully treated with a 4 electrodes (2 channel) system, as can a combined treatment for local and referred pain. The pulses delivered by TENS stimulators vary between manufacturers, but tend to be asymmetrical biphasic modified square wave pulses. The biphasic nature of the pulse means that there is usually no net DC component (often described in the manufacturers blurb as zero net DC), thus minimising any skin reactions due to the build up of electrolytes under the electrodes.

MECHANISM OF ACTION The type of stimulation delivered by the TENS unit aims to excite (stimulate) the sensory nerves, and by so doing, activate specific natural pain relief mechanisms. For convenience, if one considers that there are two primary pain relief mechanisms, which can be activated: the Pain Gate Mechanism and the Endogenous Opioid System (release hormones to mask the pain), the variation in stimulation parameters used to activate these two systems will be briefly considered. Different fibers nerve produces different types of stimulations. A stimuli happens, like when I touch something that is hot: pain mechanism is get excited by Abeta fibers, that go to the brain, then to the spinal cord..something is going on.

Pain relief by means of the pain gate mechanism involves activation (excitation) of the A beta (A) sensory fibres, and by doing so reduces the transmission of the noxious stimulus from the c fibres, through the spinal cord and hence on to the higher centres.

The A fibres appear to appreciate being stimulated at a relatively high rate (in the order of 80 - 130 Hz or pps).

An alternative approach is to stimulate the A delta (A) fibres which respond preferentially to a much lower rate of stimulation (in the order of 2 - 5 Hz, though some authors consider a wider range of 2 - 10Hz), which will activate the opioid mechanisms, and provide pain relief by causing the release of an endogenous opiate (encephalin) in the spinal cord which will reduce activation of the noxious sensory pathways.

A third possibility is to stimulate both nerve types at the same time by employing burst mode stimulation. In this instance, the higher frequency stimulation output (typically at about 100Hz) is interrupted (or burst) at the rate of about 2 - 3 bursts per second. When the machine is on, it will deliver pulses at the 100Hz rate, thereby activating the A fibres and the pain gate mechanism. For some patients this is by far the most effective approach to pain relief, though as a sensation, numerous patients find it less acceptable than some other forms of TENS as there is more of a grabbing, clawing type sensation and usually more by way of muscle twitching than with the high or low frequency modes.

There are some approaches to stimulate Agamma fibers, like TRADITIONAL TENS (HI TENS, NORMAL TENS)

Usually uses stimulation at a relatively high frequency (80 - 130Hz) and employ a relatively narrow (short duration) pulses though as mentioned above, there is less support for manipulation of the pulse width in the current research literature. Most patients seem to find best effect at around 200ms. The stimulation is delivered at normal intensity - definitely there but not uncomfortable. 30 minutes is probably the minimal effective time, but it can be delivered for as long as needed. The main pain relief is achieved during the stimulation, with a limited carry over effect i.e. pain relief after the machine has been switched off.

ACUPUNCTURE TENS (LO TENS, ACUTENS) Use a lower frequency stimulation (2-5Hz) with wider (longer) pulses (200-250ms). The intensity employed will usually need to be greater than with the traditional TENS - still not at the patients threshold, but quite a definite, strong sensation. As previously, something like 30 minutes will need to be delivered as a minimally effective dose. It takes some time for the opioid levels to build up with this type of TENS and hence the onset of pain relief may be slower than with the traditional mode. As described above, the machine is set to deliver traditional TENS, but the Burst mode is switched in, therefore interrupting the stimulation outflow at rate of 2 - 3 bursts / second. The stimulation intensity will need to be relatively high, though not as high as the `brief intense TENS more like the Lo TENS. It is proposed that the application of BURST mode TENS can effectively stimulate both the PAIN GATE and the OPIOID mechanisms simultaneously. FREQUENCY SELECTION: with all of the above mode guides, it is probably inappropriate to identify very specific frequencies that need to

be applied to achieve a particular effect. If there was a single frequency that worked for everybody, it would be much easier, but the research does not support this concept. Patients (or the therapist) need to identify the most effective frequency for their pain, and manipulation of the stimulation frequency dial or button is the best way to achieve this. Patients who are told to leave the dials alone are less likely to achieve optimal effects.

Acute pain is usually most effective between 80 and 120 Hz. Chronic pain can also benefit from lower settings 2 to 10Hz that

stimulates an endorphin release. A setting between 35 and 50Hz is commonly used to stimulate

muscles for strengthening or even relaxation. STIMULATION INTENSITY: As identified above, it is not possible to describe treatment current strength in terms of how many micro amps. The most effective intensity management appears to be related to what the patient feels during the stimulation, and this may vary from session to session. As a general guide, it appears to be effective to go for a definitely there but not painful level for the normal (high) TENS, and a strong but not painful level for the acupuncture (lo) mode. There is a growing body of evidence that suggests that a strong sensation, whichever mode is being used, might achieve better clinical effects. ELECTRODE PLACEMENT: in order to get the maximal benefit from the modality, target the stimulus at the appropriate spinal cord level (appropriate to the pain). Placing the electrodes either side of the lesion or pain areas, is the most common mechanism employed to achieve this. There are many alternatives that have been researched and found to be effective most of which are based on the appropriate nerve root level :

Stimulation of appropriate nerve root(s) Stimulate the peripheral nerve (best if proximal to the pain area) Stimulate motor point (innervated by the same root level) No Sensation Just Sensation Definite Sensation Strong Sensation Painful Stimulate trigger point(s) or acupuncture point(s) Stimulate the appropriate dermatome, myotome or sclerotome CONTRAINDICATIONS

Patient who is unable to comprehend instructions

Application over trunk, abdomen or pelvis during pregnancy TENS during labor for pain relief is both safe and effective Allergic response to electrode, gel or tape Electrode placement over dermatological lesion Anterior aspect of neck or carotid sinus Pacemakers

PRECAUTIONS Abnormal skin sensation Not over eyes Epilepsy should be treated under discretion of therapist Epiphyseal regions in children

S3 ULTRASOUND Ultrasound (US) is a form of MECHANICAL energy, not electrical energy and therefore strictly speaking, not really electrotherapy at all but does fall into the Electro Physical Agents grouping. Mechanical vibration at increasing frequencies is known as sound energy. The normal human sound range is from 16Hz to something approaching 15-20,000 Hz (in children and young adults). Beyond this upper limit, the mechanical vibration is known as ULTRASOUND. The frequencies used in therapy are typically between 1.0 and 3.0 MHz (1MHz = 1 million cycles per second) Sound waves are LONGITUDINAL waves consisting of areas of COMPRESSION and RAREFACTION. Particles of a material, when exposed to a sound wave will oscillate about a fixed point rather than move with the wave itself. As the energy within the sound wave is passed to the material, it will cause oscillation of the particles of that material. Any increase in the molecular vibration in the tissue can result in heat generation, and ultrasound can be used to produce thermal changes in the tissues, though current usage in therapy does not focus on this phenomenon FREQUENCY - the number of times a particle experiences a complete compression/rarefaction cycle in 1 second. Typically 1 or 3 MHz (though there are devices which operate in the kHz range WAVELENGTH - the distance between two equivalent points on the waveform in the particular medium. In an average tissue the wavelength @ 1MHz would be 1.5mm and @ 3 MHz would be 0.5 mm.

VELOCITY - the velocity at which the wave (disturbance) travels through the medium. In a saline solution, the velocity of US is approximately 1500 m sec-1 compared with approximately 350 m sec-1 in air (sound waves can travel more rapidly in a more dense medium). The velocity of US in most tissues is thought to be similar to that in saline. All materials (tissues) will present impedance to the passage of sound waves. The specific impedance of a tissue will be determined by its density and elasticity. In order for the maximal transmission of energy from one medium to another, the impedance of the two media needs to be as similar as possible. In the case of US passing from the generator to the tissues and then through the different tissue types, this cannot actually be achieved. The difference in impedance is greatest for the steel/air interface which is the first one that the US has to overcome in order to reach the tissues. To minimise this difference, a suitable coupling medium has to be utilised. If even a small air gap exists between the transducer and the skin the proportion of US that will be reflected approaches 99.998% which means that there will be no effective transmission. The coupling media used in this context include water, various oils, creams and gels. Ideally, the coupling medium should be fluid so as to fill all available spaces, relatively viscous so that it stays in place, have an impedance appropriate to the media it connects, and should allow transmission of US with minimal absorption, attenuation or disturbance. At the present time the gel based media appear to be preferable to the oils and creams. Water is a good media and can be used as an alternative but it fails to meet the above criteria in terms of its viscosity. The absorption of US energy follows an exponential pattern - i.e. more energy is absorbed in the superficial tissues than in the deep tissues. In order for energy to have an effect it must be absorbed, and at some point this must be considered in relation to the US dosages applied to achieve certain effects

As the penetration (or transmission) of US is not the same in each tissue type

some tissues are capable of greater absorption of US than others. Generally, the tissues with the higher protein content will absorb US to a greater extent, tissues with high water content and low protein content absorb little of the US energy (e.g. blood and fat) those with a lower water content and a higher protein content will absorb US far more efficiently.

Most machines offer the facility for pulsed US output

The pulse ratio determines the concentration of the energy on a time basis. The pulse ratio determines the proportion of time that the machine is ON compared with the OFF time. A pulse ratio of 1:1 for example means that the machine delivers one 'unit' of ultrasound followed by an equal duration during which no energy is delivered. The machine duty cycle is therefore 50%. A machine pulsed at a ratio of 1:4 will deliver one unit of ultrasound followed by 4 units of rest, therefore the machine is on for 20% of the time The selection of the most appropriate pulse ratio essentially depends on the STATE of the tissues. The more acute the tissue state, the more energy sensitive it is, and appears to respond more favourably to energy delivered with a larger pulse ratio (lower duty cycle). As the tissue moves away from its acute state, it appears to respond preferentially to a more 'concentrated' energy delivery, reducing the pulse ratio (or increasing the duty cycle). 1:4 or 1:3 for the ACUTE lesions (10-20%) 1:2 and 1:1 for the SUBACUTE lesions (25-33%) and 1:1 or Continuous for the CHRONIC lesions (50-100%) In a similar way to the pulse ratio decision, the intensity of ultrasound required at the target tissue will vary with the tissue state. The more acute the lesion, the less strong the ultrasound needs to be in order to achieve/maintain the tissue excitement. The more chronic the tissue state, the less sensitive, and hence the greater the intensity required at the lesion in order to instigate a physiological response. Tissue State / Intensity required at the lesion (W/cm2) Acute 0.1 - 0.3 Sub Acute 0.2 - 0.5 Chronic 0.3 - 0.8 INDICATIONS Best used in tissues with high collegen content Ligaments Tendons Fascia Joint capsule and scar tissue Soft tissue shortening such as joint contracture, scarring, adhesive capsulitis, duputrens contracture. Subacute and chronic inflammation. Muscle guarding

Myofascial trigger points, Sprain strain injuries, Bursitis and tendonitis, Edema reduction CONTRAINDICATIONS: Do not expose either the embryo or foetus to therapeutic levels of ultrasound by treating over the uterus during pregnancy Malignancy (history of malignancy is NOT a contraindication DO NOT treat over tissue that is, or considered to be malignant) Tissues in which bleeding is occurring or could reasonably be expected (usually within 4-6 hours of injury but may be longer in some instances and for some patients) Significant vascular abnormalities including deep vein thrombosis, emboli and severe arteriosclerosis / atherosclerosis (if increase in local blood flow demanded by the treatment can not reasonably be delivered) Haemophiliacs not covered by factor replacement Avoid Application over:

The eye The stellate ganglion The cardiac area in advanced heart disease & where pacemakers

in situ The gonads Active epiphyses in children

PRECAUTIONS Always use the lowest intensity which produces a therapeutic

response Ensure that the applicator is moved throughout the treatment

(speed and direction not an issue) Ensure that the patient is aware of the nature of the treatment

and its expected outcome If a thermal dose is intended, ensure that any contraindications

that apply have been considered Caution is advised in the vicinity of a cardiac pacemaker or other

implanted electronic device Continuous ultrasound is considered unwise over metal implants

Reversible blood cell stasis can occur in small blood vessels if a standing wave is produced while treating over a reflector such as an air/soft tissue interface, soft tissue/bone or soft tissue/metal interface whilst using a stationary applicator. Continuous movement of the treatment head negates this hazard. Treatment with a stationary treatment head is considered bad practice The operator should note:

Machine (if more than one available) Machine settings: frequency, intensity, time, pulse parameters Area treated (size and location) Any immediate or untoward effects

The greater the size of the lesion, the longer the duration of the ultrasound that will be required in order to achieve a particular effect. The most common method to take account of this factor is to estimate the number of times which the ultrasound treatment head to be utilised can be placed over the target tissue. The final compilation of the treatment dose which is most likely to be effective is based on the principle that one needs to deliver 1 minutes worth of ultrasound energy (at an appropriate frequency and intensity) for every treatment head that needs to be covered. The size of the treatment area will influence the treatment time, as will the pulse ratio being used. The larger the treatment area, the longer the treatment will take. The more pulsed the energy output from the machine, the longer it will take to deliver 1 minutes worth of ultrasound energy Working on the principle of 1 minutes worth of ultrasound per treatment head area, the total time taken to treat the lesion will be (1 minute) x (number of times the treatment head fits over the lesion) x (the pulse ratio) [the factor to account of the pulsing can be easily worked out by adding together the two components of the pulse ratio thus, pulsing 1:4, adds up to 5, so multiply by 5. Pulse at 1:2, adds up to 3, so multiply by 3 etc] EXAMPLE:

acute lesion of the lateral collateral ligament of the knee The lesion is superficial, hence a 3MHz frequency would be most appropriate The lesion is acute, thus an intensity of 0.2 W/cm2 should be sufficient to treat the lesion There is no need to increase the surface dose to allow for loss of ultrasound at depth. The lesion is acute, therefore a pulse ratio of 1:4 will be most appropriate Using the treatment head, it is estimated that the target tissue is approximately the same size as the treatment head (i.e. the head fits on to the tissue once) the total time taken to treat the lesion will be (1 minute) x (number of times the treatment head fits over the lesion) x (the pulse ratio) which in this instance = (1) x (1) x (5) = 5 minutes

The final treatment dose will therefore be 3MHz ; 0.2 W/cm2 ; Pulsed 1:4 ; 5 minutes

subacute lesion of the lateral collateral ligament of the elbow and superior radioulnar joint

The lesion is superficial, hence a 3MHz frequency would be most appropriate The lesion is sub-acute, thus an intensity of 0.4 W/cm2 There is no need to increase the surface dose to allow for loss of ultrasound at depth The lesion is sub-acute, therefore a pulse ratio of 1:2 will be most appropriate Using the small treatment head (due to the nature of the surface), it is estimated that the target tissue is approximately twice the size of the treatment head (i.e. the head fits on to the tissue twice) the total time taken to treat the lesion will be (1 minute) x (number of times the treatment head fits over the lesion) x (the pulse ratio) which in this instance = (1) x (2) x (3) = 6 minutes. The final treatment dose will therefore be 3MHz ; 0.4 W/cm2 ; Pulsed 1:2 ; 6 minutes

chronic lesion of the anterior capsule of the shoulder (glenohumeral joint)

The lesion is not superficial, hence a 1MHz frequency would be most appropriate The lesion is chronic, thus an intensity of 0.5 W/cm2 The lesion is chronic, therefore a pulse ratio of 1:1 will be most appropriate Using the treatment head, it is estimated that the target tissue is approximately twice the size of the treatment head (i.e. the head fits on to the tissue twice) (1 minute) x (number of times the treatment head fits over the lesion) x (the pulse ratio) which in this instance = (1) x (2) x (2) = 4 minutes. The final treatment dose will therefore be 1MHz ; 0.5 W/cm2 ; Pulsed 1:1 ; 4 minutes

chronic lesion of the gastrocnemius musculotendinous junction The lesion is relatively superficial, hence a 3MHz frequency would be most appropriate (this may not be true for some patients) The lesion is very chronic, thus an intensity of at least 0.8 W/cm2

The lesion is particularly chronic, therefore a continuous mode will be most appropriate Using the treatment head, it is estimated that the target tissue is approximately three times the size of the treatment head. (1 minute) x (number of times the treatment head fits over the lesion) x (the pulse ratio) which in this instance = (1) x (3) x (1) = 3 minutes. The final treatment dose will therefore be: 3MHz ; 0.8 W/cm2 Continuous; 3 minutes S4 INTERFERENTIAL CURRENT IFC The basic principle of Interferential Therapy (IFC) is to utilise the significant physiological effects of low frequency (

low frequency stimulation in effect the interference mimics a low frequency stimulation. QUAD VS PRE MOD The key difference is that with a 4 pole application the interference is generated in the tissues and with a 2 pole treatment, the current is pre modulated i.e. the interference is generated within the machine unit FREQUENCY SWEEP Nerves will accommodate to a constant signal & a sweep (or gradually changing frequency) is often used to overcome this problem. The principle of using the sweep is that the machine is set to automatically vary the effective stimulation frequency using either pre-set or user set sweep ranges. The sweep range employed should be appropriate to the desired physiological effects (see next slide). It has been repeatedly demonstrated that wide sweep ranges are ineffective whenever they have been tested or evaluated in the clinical environment The pattern of the sweep makes a significant difference to the stimulation received by the patient. Most machines offer several sweep patterns, though there is very limited evidence to justify some of these options. In the classic triangular sweep pattern, the machine gradually changes from the base to the top frequency, usually over a time period of 6 seconds though some machines offer 1 or 3 second options

In the example illustrated, the machine is set to sweep from 90 to 130Hz employing a triangular sweep pattern. All frequencies between the base and top frequencies are delivered in equal proportion. Other patterns of sweep can be produced on many machines, for example a rectangular (or step) sweep. This produces a very different stimulation pattern in that the base and top frequencies are set, but the machine then switches between these two specific frequencies rather than gradually changing from one to the other. The adjacent diagram illustrates the effect of setting a 90 130Hz rectangular sweep Selection of a wide frequency sweeps has been considered less efficient than a smaller selective range in that by treating with a frequency range of say 1-100Hz, the effective treatment frequencies can be covered, but only for a relatively small percentage of the total treatment time. CLINICAL APPLICATION

1. Pain relief 2. Muscle stimulation 3. Increased local blood flow 4. Reduction of edema

1. PAIN RELIEF Electrical stimulation for pain relief has widespread clinical use, thought the direct research evidence for the use of IFC in this role is limited. Logically one could use the higher frequencies (90-130Hz) to stimulate the pain gate mechanisms & thereby mask the pain symptoms. Alternatively, stimulation with lower frequencies (2-5Hz) can be used to activate the opioid mechanisms, again providing a degree of relief. 2. MUSCLE STIMULATION Stimulation of the motor nerves can be achieved with a wide range of frequencies. stimulation at low frequency (e.g. 1Hz) will result in a series of twitches, whist stimulation at 50Hz will result in a tetanic contraction.

Caution should be exercised when employing IFC as a means to generate levels of muscle contraction It is possible to continue to stimulate the muscle beyond its point of fatigue the contractions are forced via the motor nerve and short stimulation periods with adequate rest might be a preferable option. 4. REDUCTION OF EDEMA IFC has been claimed to be effective as a treatment to promote the reabsorption of edema in the tissues. Again, the evidence is very limited in this respect and the physiological mechanism by which is could be achieved as a direct effect of the IFC remains to be established The preferable clinical option in the light of the available evidence is to use the IFC to bring about local muscle contraction which combined with the local vascular changes that could be effective in encouraging the reabsorption of tissue fluid. The use of suction electrodes may be beneficial, but also remains unproven in this respect. TREATMENT PARAMETERS Stimulation can be applied using pad electrodes and sponge covers (which when wet provide a reasonable conductive path), though electroconductive gel is an effective alternative. The sponges should be thoroughly wet to ensure even current distribution. Self adhesive pad electrodes are also available (similar to the newer TENS electrodes) and make the IFC application easier in the view of many practitioners. The suction electrode application method has been in use for several years, and whilst it is useful, especially for larger body areas like the shoulder girdle, trunk, hip, knee, it does not appear to provide any therapeutic advantage over pad electrodes

Treatment times vary widely according to the usual clinical parameters of acute/chronic conditions & the type of physiological effect desired.

In acute conditions, shorter treatment times of 5-10 minutes may be sufficient to achieve the effect. In other circumstances, it may be necessary to stimulate the tissues for 20-30 minutes. It is suggested that short treatment times are initially adopted especially with the acute case in case of symptom exacerbation. These can be progressed if the aim has not been achieved and no untoward side effects have been produced INTERFERENTIAL CONTRAINDICATIONS Patients who do not comprehend the physiotherapists instructions or are unable to co-operate should not be treated Patients with Pacemakers some pacemakers are relatively immune to interference from electrical stimulation whilst others can demonstrate serious adverse behaviour. It is suggested that as a general rule, if the patient has a pacemaker, it is best to avoid all electrical stimulation, but like TENS, if it is a treatment that is needed. The stimulation should be tried in a carefully controlled environment where appropriate equipment is available to correct any pacing problems should they arise. Patients who are taking anticoagulation therapy or have a history of pulmonary embolism or deep vein thrombosis should not be treated with the vacuum electrode applications. Similarly, patients whose skin may be easily damaged or bruised APPLICATION OVER:

The trunk or pelvis during pregnancy (though this MAY be modified in time in line with the TENS advice. At the present time, it is suggested that it is best avoided in these regions)

Active or suspected malignancy except in hospice/palliative/terminal care

The eyes The anterior aspect of the neck The carotid sinuses Dermatological conditions e.g. dermatitis, broken skin Danger of haemorrhage or current tissue bleeding (e.g. recent soft

tissue injury) Avoid active epiphyseal regions in children

INTERFERENTIAL PRECAUTIONS Care should be taken to maintain the suction at a level below that which causes damage / discomfort to the patient If there is abnormal skin sensation, electrodes should be positioned in a site other than this area to ensure effective stimulation

Patients who have (marked) abnormal circulation For patients who have febrile conditions, the outcome of the first treatment should be monitored Patients who have epilepsy, advanced cardiovascular conditions or cardiac arrhythmias should be treated at the discretion of the physiotherapist in consultation with the appropriate medical practitioner Treatment that involves placement of electrodes over the anterior chest wall INTERFERENTIAL TREATMENT RECORD Electrode number (2 pole, 4 pole) and positions Frequency applied Sweep settings employed (if applicable) Current intensity applied (or patient reported sensation) Treatment duration. S5. LASER THERAPY The term LASER is an acronym for the Light Amplification by Stimulated Emission of Radiation. In simple yet realistic terms, the laser can be considered to be a form of light amplifier - it provides enhancement of particular properties of light energy Laser light will behave according to the basic laws of light, in that it travels in straight lines at a constant velocity in space. It can be transmitted, reflected, refracted and absorbed. It can be placed within the electromagnetic spectrum according to its wavelength/frequency which will vary according to the particular generator under consideration.

LLLT involves treatment with a dose that causes no detectable temperature rise in the treated tissues and no macroscopically visible change in tissue structure essentially, the energy can cause in increase in temperature and a change in tissue structure, but that is

not the intention with therapy laser which is applied at levels below that needed to achieve these more overt effects PARAMETERS Most LLLT apparatus generates light in the Red Visible & Near Infra-red bands of the EM spectrum, with typical wavelengths of 600 -1000nm. The mean power of such devices is generally low (1-100mW), though the peak power may be much higher than this. The treatment device may be a single emitter or a cluster of several emitters, though it is common for most emitters in a cluster to be non laser type devices. The beam from single probes is usually narrow (1mm-6 or 7mm) at the source. A cluster probe will usually incorporate both higher and lower power emitters of different wavelengths.

The output may be continuous or pulsed, with narrow pulse widths (in the nano or micro second ranges) and a wide variety of pulse repetition rates from 2Hz up to several thousand Hz. LIGHT ABSORPTION IN THE TISSUES As with any form of energy used in electrotherapy, the energy must be absorbed by the tissues in order to have some effect. The absorption of

light energy within the tissues is a complex issue, but generally, the shorter wavelengths (ultraviolet & shorter visible) are primarily absorbed in the epidermis by the pigments, amino & nucleic acids. The longer IRR wavelengths (>1300nm) appear to be rapidly absorbed by water & therefore have a limited penetration into the tissues.The band between (i.e. 600-1000nm) are capable of penetration beyond the very superficial epidermis & are, in part at least, available for absorption by other biological tissues. LLLT when applied to the body tissues, delivers energy at a level sufficient to disturb local electron orbits & result in the generation of heat, initiate chemical change, disrupt molecular bonds & produce free radicals. TISSUE INTERACTION As with many other forms of energy delivered to the patient under the umbrella of electrotherapy, the primary effects are divided into thermal and non thermal. LLLT is generally considered to be a non thermal energy application, though one must be careful to appreciate that

delivery and absorption of any energy to the body will result in the development of heat to some extent. Photobioactivation is a commonly used phrase in connection with LILT - meaning the stimulation of various biological events using light energy but without significant temperature changes. The following list of physiological & cellular level effects

Altered cell proliferation Altered cell motility Activation of phagocytes Stimulation of immune responses Increased cellular metabolism Stimulation of macrophages Stimulation of mast cell degranulation Activation & proliferation of fibroblasts Alteration of cell membrane potentials Stimulation of angiogenesis Alteration of action potentials Altered prostaglandin production Altered endogenous opioid production

DOSAGE Most research groups and many manufacturers, recommend that the dose delivered to a patient during a treatment session should be based on the ENERGY DENSITY rather than the power or other measure of dose. Energy Density is measured in units of Joules per square centimetre (J/cm2). One of the most significant inhibitors to the more widespread adoption of laser therapy in the clinical environment relates to the difficulty in getting these effective laser doses to work on a particular machine. Few devices enable the practitioner to set the dose in J/cm2. Some will provide Joules, some Watts, some watts/cm-2 etc.. Some machines offer 'on board' calculations of this dose, whilst other machines require the operator to make some simple calculations based on several considerations:

output power (Watts) irradiation area (cm2) time (seconds) If PULSED - pulse width, frequency and power settings

CLINICAL APPLICATIONS Most dominant amongst these are: wound healing, inflammatory arthropathies, soft tissue injury

the relief of pain. OPEN WOUNDS There is a growing body of evidence in this context, with some mixed results, but on the whole, they are positive outcome trials. Treat to the floor of the ulcer / pressure sore / wound Often use cluster probe to cover the area Typically up to 2 J/cm2 Also treat margin/periphery Often use single probe Typically up to 4 J/cm2

INFLAMMATORY ARTHROPATHIES There have been several trials involving the use of LILT and various inflammatory problems in joints. As with the wound work, there are mixed results, but the general trend appears to be largely supportive. The recent Ottawa Panel review was supportive of laser therapy in RA.

SOFT TISSUE INJURY There is a fairly widespread use of LILT in a variety of soft tissue treatments. Some results are excellent and others poor. It is possible that the weak results relate to incorrect doses or possibly considering the use of laser therapy for injuries that are simply beyond the reach of the energy delivered

PAIN RELIEF It was broadly assumed (until more recently) that the effect of laser therapy with regards to pain relief was primarily a secondary effect of dealing with the inflammatory state. Whilst this may well be true (to some extent at least), there is growing evidence that laser therapy can have a more direct effect of nerve conduction characteristics and hence may result in reduced pain as a more direct effect of the therapy. CONTROINDICATIONS:

Direct Irradiation of eyes Pregnancy over abdomen Carcinoma Over Endocrine Glands

S6. THERMAL THERAPY The amount of energy a tissue gains or loses depends on several factors:

Nature of the tissue Agent used Duration of exposure

Temperature has an effect on: Viscosity Nerve conductionheat increases nerve conduction velocity; cold

decreases it Blood flowheat increases arterial and capillary blood flow; cold

decreases blood flow Collagen extensibilityheat increases tendon extensibility,

collagenase activity is increased; cold decreases enzyme activity Temperatures > 4550C (113122 F) or < 0C (32F) can injure

tissue HEAT Therapeutic uses for heat are based on:

Hyperemia- blood flow Analgesia- pain Hyperthermia - body temperature Decreased muscle tone Increase in collagen elasticity

Applications for heat therapy Generally used for chronic process Decrease muscle spasms Decrease pain (myofascial, low back, neck, post herpetic neuralgia) Reduction in joint stiffness, contractures Arthritis, collagen vascular diseases Chronic inflammation Superficial thrombophlebitis

CONVECTION Contact between two surfaces at different temperatures with resultant flow of one past the other. Conveyance of heat in liquids or gases by the movement of heated particles. The flow increases the temperature gradient between the surfaces maximizing heating and cooling. More intense than conduction.Examples:

Fluidotherapy Hydrotherapy (whirlpool) Contrast baths

CONDUCTION HEATING Transfer of heat between two bodies at different temperatures. Movement of heat without movement of conducting body. Examples:

Hot water Paraffin Hot packs (hydro collator packs)

CONVERSIVE HEATING

Nonthermal energy converts to heat in the tissues. Examples: Radiant heat (heat lamps) Shortwave diathermy Ultrasound Microwave

SUPERFICIAL VS DEEP HEAT Superficial Heat Maximum tissue temperature is achieved in skin and subcutaneous fat.

Used to heat joints with little soft tissue covering (hand, foot), or cause a deeper effect through reflex mechanisms (for relief of muscle spasms) CONVECTIVE AGENTS

Fluidotherapy Hot air is blown through a container holding fine cellulose particles (bed

of beads or corn husks), which produces a warm air-fluid mixture with properties similar to liquid

Advantages: massage action of the turbulent solid-gas mixture; freedom to perform ROM activities

Good for hands and feet Agitation level and temperature can be controlled. The typical

temperature range is 46.148.9 C/115120 F

HYDROTHERAPY

External use of water to treat a physical condition. Water can be used to produce convective heating or cooling, massage, and gentle debridement

Unit size, water temperature, agitation intensity, and solvent properties can be adjusted to meet treatment goals:

Whirlpool bathsfor partial body immersion Hubbard tanksused for total body immersion The water temperature can be selected

depending on the amount of body submerged, patient's health and goals of treatment:

Whirlpool temperature for Upper limbs is 37.840.6 C (100105 F) Lower limbs is 37.838.9 C (100102 F) Hubbard tanksThe temperature should be less than 39 C (102.2 F)

to avoid systemic problems (can change core body temperature) Mild heating: 36.737.2 C (9898.9 F).

Vigorous heating: 37.838.3 F (100100.9 F) Give treatment for approximately 10 to 20 minutes, depending on the

patient's cardiopulmonary tolerance. CONTRAINDICATIONS FOR HUBBARD TANKS:

Patients incontinent of bowel and bladder Skin infections Unstable blood pressure Uncontrolled epilepsy Acute febrile episodes Upper respiratory infections Tuberculosis Multiple sclerosis

CONTRAST BATHS Distal limbs receive alternating heat and cold in a whirlpool tank to produce reflex hyperemia. Temperatures range from hot 3844 C or 100.4 to 111 F, and cold 1018 C or 5064.4 F Technique: begin with warm soaks to the extremity, then follow with four cycles of alternating 14 minute cold soaks and 46 minutes warm soaks

Uses: Rheumatoid arthritis, reflex sympathetic dystrophy, to toughen residual limbs; muscular strains and joint sprains. Contraindications: small vessel disease caused by diabetes, arteriosclerotic endarteritis or Burger's disease.

CONDUCTIVE AGENTS HOT PACKS

Hydrocollator: canvas bags filled with silicon dioxide immersed in tanks of heated water (74.5 C/166 F)

Applied over several layers of insulating towels Heat treatment lasts 30 minutes Lehman (1966): Hot pack to posterior thigh increased temperature to 3.3 C at 1 cm depth, 1.3 C at 2 cm depth

Advantages: low cost, minimal maintenance, long life patient acceptance, ease of use

Disadvantages: Prolonged superficial heat can produce temporary or permanent skin mottlingerythema abigne. This condition is characterized by reticular pigmentation and telangiectasia. HEATING PADS

Available as electric pads and pads with circulating heated fluid such as water.

Peak temperature is 52 C (125 F) The temperature is maintained at a constant level, no spontaneous

cooling If used with moist towels there is a potential risk for electrical shock If the patient lies on the pad there is a potential for burns. This is

common in patients with decreased adipose tissue Generally used for periods of 20 minutes

PARAFFIN BATH Paraffin wax and mineral oil in a 7:1 or 6:1 ratio heated to 52.254.4

C (126130 F) Commonly used in irregular surfaces such as distal extremities

CONVERSIVE AGENTS Radiant heat (Infrared lamps) Energy is absorbed through the skin and converted to superficial heat. Distance from the lamp to skin is usually 4560 cm (1824 inches),

and is applied for 2030 minutes. Most lamps act as point sources and their heating effectiveness decreases with the square of their distance from the body (1/r2 law).

Used in patients who cannot tolerate the weight of hot packs Precautions: general heat precautions, light sensitivity (dermal photo-

aging) and skin drying, photosensitizing medications DEEP HEAT

Tissue temperature can be increased to a depth of 35 cm or more without overheating subcutaneous tissue or skin. Produced by conversion of energy into heat, and may penetrate to deep structures such as ligaments, bones, muscles, and joint capsules.

Ultrasound Short wave diathermy Microwave diathermy

CONTRAINDICATIONS FOR HEAT THERAPY Ischemiae.g., arterial insufficiency Metabolic requirement of the limbs is increased with the use of heat.

(Note: for every 10 increase in skin temperature, there is a 100% increase in metabolic demand.)

Bleeding disorders (e.g., hemophilia), Hemorrhagethere is an increased arterial and capillary blood flow with heat

Impaired sensatione.g., spinal cord injury (SCI) may predispose to burns

Inability to communicate or respond to paine.g., dementia MalignancyMay increase tumor growth Acute trauma or inflammationDiffusion across membranes is

increased EdemaDiffusion across membranes is increased Atrophic skin Poor thermal regulation

CRYOTHERAPY Therapeutic effects of cold are based on the following

Immediate local vasoconstriction Local metabolism decrease Decreased acute inflammatory response Slows nerve conduction velocitydecreased motor and sensory nerve

conduction. Decreased muscle spindle activitydecreased firing rates of Ia and II

afferent fibers Decreased pain/muscle spasmincreases nerve pain threshold Decreased spasticity Increased tissue viscosity with decreased tissue elasticity Transient increase in systolic and diastolic blood pressure Release of vasoactive agents (histamine) Indications for cold therapy Generally used for acute process Acute traumatic conditionsreduction of inflammation and edema in

the 2448 hour period. Musculoskeletal conditionsarthritis, bursitis Acute and chronic pain Spasticity management Immediate treatment of minor burns

Mechanisms of cold transfer Conduction: Cold packs, ice massage Convection: Cold baths (whirlpool) Evaporation: Vapo-coolant spray The treatment modality depends on the size of the area to be treated

and how accessible it is for cold application. CONDUCTION

COLD PACKS Include ice packs, wraps and sluices, endothermic chemical gel packs

and hydrocollator packs The pack is wrapped in moist towels and treatment time is generally

2030 minutes Surface skin temperature can decrease by 15 C after 10 minutes,

subcutaneous temperatures decrease by 35 C muscle cooling by 5 C at a depth of 2 cm after 20-minute application

of a hydrocollator pack ICE MASSAGE

For cooling of small areas (muscle belly, tendon, trigger point) before applying deep pressure massage. Combines the therapeutic effect of ice with the mechanical effects of massage

Direct application of ice to a painful area using gentle stroking motion a reduction of intramuscular temperature by 4.1 C at 2 cm. depth in

the posterior thigh region, and up to 15.9 C reduction in biceps brachii after the 5-minute application time

Treatment of analgesia can be obtained in 710 minutes CONVECTION

COLD BATHS An example of hydrotherapy; uses water-filled containers for distal limb

immersion Best suited for circumferential cooling of the limbs Water temperature: 410 C Can be uncomfortable and poorly tolerated Effective for treatment of localized burns due to rapid skin temperature

reduction

EVAPORATION Vapo-coolant sprays Volatile liquids such as Fluori-methane spray are commonly used Used for spray-and-stretch techniques to treat myofascial pain ; also

used for local anesthesia Produce an abrupt temperature change over a small surface area Precautions: risk for skin site irritation and local cutaneous freezing

CRYOTHERAPY COMPRESSION UNITS Combines the benefits of cold with the advantages of pneumatic

compression Uses sleeves with circulating cold water, attached to an intermittent

pump unit. Edematous extremities are placed inside the sleeves

Used primarily to treat acute musculoskeletal injury with soft tissue swelling. Also used after some surgical procedures

Temperatures used are 45F (7.2 C) and pressures up to 60 mmHg CONTRAINDICATIONS

Cold intolerance, hypersensitivity to cold (Raynaud's disease/phenomenon)

Arterial insufficiencyareas with circulatory compromise such as ischemic areas in patients with peripheral vascular disease affecting the arterial system

Impaired sensationinsensate skin is at risk for burns Cognitive and communication deficits that preclude the patient from

reporting pain Cardiac, respiratory involvementif severe HTN present, the patient's

BP must be monitored closely Cryotherapy induced neuropraxia/axonotmesis, regenerating peripheral

nerves Open wounds after 48 hours Note: Reflex vasodilation with hyperemia can occur after removal of ice

S7. PARAFFIN WAX

Paraffin wax bath therapy is an application of the molten paraffin

wax on the body part. It is one of the most convenient & effective methods of

applying heat to the skin. The temperature of the paraffin wax is maintained at 47

- 55c. The combination of the wax and the mineral oil has low specific heat which enhances the patients ability to tolerate heat from the wax better than from the water of the same temperature.

The composition of the wax: paraffin: mineral oil is 7:3:1 or Wax: paraffin or mineral oil is 7:1. The mode of the transmission of heat from paraffin to the patient skin is by means conduction. CHARACTERISTICS OF WAX

Low thermal conductivity Gives of heat very slowly no rapid loss of heat Melting point of wax is 55C

It is self - insulating. (The first layer creates a thin layer of air next to the skin which acts as an insulator) PARTS OF PARAFFIN WAX

Container, Mains, Thermostat, Thermostat pilot lamp, Power pilot lamp, Lid, and Caster.

1. Container is made-up of enamelled baths or stainless steel bowl and outer fiberglass shell.

2. Initially heating is quicker with this type because there is no water jacket to be heated.

3. Container contains wax and paraffin oil in the prescribed ratio. 4. Main function is to switch on or off the heating element, which is

located in the casing of paraffin wax bath unit. 5. Thermostat keeps the temperature fix or static in the range which is

adjusted with knob. Thermostat pilots lamp indicates whether thermostat is on or off.

6. Power pilots lamp function is to show whether power is on or off. 7. Lid cover container and caster allow the paraffin wax bath container

to be move from 1 place to another. PHYSIOLOGICAL EFFECTS HEAT PRODUCTION:

There is a marked increase in skin temperature in the 1st two minute, up to 12-13c. This drop, while in the wax wrapping to an increase of about 8c at the end of 30 minutes.

In the subcutaneous fascia, there is an increase of 5c at the end of the treatment.

In the superficial muscles, is only about 2-3c rise in temperature at the end of the treatment CIRCULATING EFFECT:

Stimulation of superficial capillaries and arterioles cause local hyperaemia and reflex vasodilatation. This is marked only in the region of the skin.

The hyperaemia is due to response of the skin to its function of heat regulation.

The effects of vasodilatation in the muscle are negligible, but then may be some reflex heating in the joints.

Skin and subcutaneous tissue temperature drop after15-20 minute, reducing the vasodilatation

Exercise after the wax is essential to increase the muscle circulation and sedative effect of heat to obtain more range of movement and muscle strength.

ANALGESIC EFFECT: The most important effect of wax its marked sedative effect on the

tissue. The moist heat is remarkable soothing to the patient. It is this effect that is used prior to the exercise, in the treatment of

superficially placed joints. It is very comfortable to the patient.

STRETCHING EFFECT: Wax leaves the skin moist, soft and pliable. This is useful for stretching scar and adhesion before applying

mobilization techniques. INDICATIONS

1. Pain and Muscle Spasm: Wax reduces the pain and muscle spasm. 2. Edema and Inflammation:

The gentle heat reduces post-traumatic swelling of the hands and feet and also swelling in hands affected by rheumatoid arthritis or degenerative joint disease, particularly in the sub-acute and early chronic stages of inflammation.

3. Adhesions and Scars: Wax softens the adhesion and scar in the skin and thus facilitates the

mobilization and stretching procedures. CONTRAINDICATIONS

1. Impaired skin sensation: This will be determined by a hot/cold skin test.

2. Some Dermatological conditions: Are exacerbated by moist heat, such as eczema, athletes foot and dermatitis. Any dermatological condition, which appears after treatment, must be reported.

3. Circulatory Dysfunction: Patients with varicose veins, deep vein thrombosis and arterial disease must not have any heat applied directly over the affected part.

4. Analgesic Drugs: If patients are taking strong narcotics for pain, the time and dosage of the drugs must be ascertained. Heat is not administered immediately after intake of drugs, since pain tolerance to heat is impaired.

5. Infections and open wounds: Heat will increase the infective activity. 6. Cancer or tuberculosis:

In the area to be treated, heat, by increasing the metabolic rate, may increase the rate of growth and spread the disease.

7. Gross edema: With a very thin and delicate skin covering the area, the skin may be

damaged and the heat may tend to increase the edema. 8. Lack of comprehension:

Patients who cannot understand the nature of the treatment and comprehend the potential danger, for example, children, very old patients, other nationalities.

9. Acute injury or Inflammation 10. Recent or Potential hemorrhage

PRECAUTIONS: 1. Cardiac insufficiency 2. Metal in the area

Advantages of Paraffin wax Low specific heat allows for application at a higher

temperature than water without the risk of a burn. Low thermal conductivity allows for heating of tissues to

occur more slowly, thus reducing the risk of overheating the tissues.

Molten state allows for even distribution of heat to areas like finger and toes.

First dip traps air and moisture (Insulation) to create more even heat distribution.

Oils used in the wax add moisture to the skin. Wax remains malleable, after removal. Comfortable, moist heat. Relative inexpensive to replace wax. It can be carried out at home for the chronic sufferers. Useful for patients with poor heat tolerance Two or Three patients can be treated at a time.

DISADVANTAGES Effective only for distal extremities in the terms of ease of

application. No method of temperature controls once applied. Sedimentation occurs at the bottom. It is a passive treatment: exercise may not be performed

simultaneously. The bath must be cleaned regularly & emptied at least twice a

year. Contamination of oil by atmospheric dust.

It also poses environmental concerns regarding its disposal. HOW TO USE IT The nature of wax treatment is explained and the area to be

treated is inspected for contraindication. Look for any wound, skin infection, rashes etc. on the part to be

treated. Wash the area thoroughly & dry by using tissue paper or cotton. Tell the patient in brief about temperature of the wax and

benefits Drip down few drops of molten wax on the dorsal surface of your

hand or ask the patient to dip the PIP joint to check the temperature.

This is done before; the patient so that he/she can prepare psychologically and fear of heat is minimized.

The patient is instructed to remove any jewelry or metal in the area.

Position of the patient should be such that the part to be treated comes closer to the wax bath container.

Instruct the patient to avoid touching the sides and bottom of the heating unit because burns may result

Instruct the patient who is receiving an immersion method not to move the joints that are in the liquid. The cracking of the wax will allow fresh paraffin to touch the skin, increasing the risk of burns.

The warm wax is placed on the body tissues by various techniques and the treatment is given for about 10-20 minutes.

TECHNIQUES DIRECT POURING METHOD: In this method the part is positioned over a large bowl or on top

of tank itself & the molten Wax is directly poured by a mug or utensil on the part to be treated.

The wax is allowed to solidify. Several (4-6) layers can be made over the body tissues and

then wrapped around by a towel to prevent heat loss. It is maintained for about 10-20 minutes & the wax is removed

into tank for reuse. BRUSHING / PAINTING METHOD: If the part cant be immersed in wax, it is possible to coat the

surface with the help of paint brush. It is a less commonly used method.

This method is used for areas like hip, knee, elbow, shoulder and more body parts.

In this method, 8-10 coats of wax are applied to the area with a paint brush using even and rapid strokes.

The area is then wrapped with towel for 10-20 minutes and after this time, paraffin wax is removed and discarded.

This is useful if the patient cant tolerate dry heat & hydrocollator packs are not available.

DIP & IMMERSE / DIP & LEAVE IN METHOD: This method of application provides somewhat vigorous heating.

Commonly used for the distal parts of the extremities such as hands & feet.

The body part to be treated dipped 3-4 time to form a thin coat and then left immersed in paraffin wax for 20-30 minutes

A thin glove of solid paraffin wax formed slows the heat conduction.

This method is more effective in raising tissue temperature, but places the patient at greater risk for burns.

Use of immersion method required co-operation and tolerance by the patient.

This method does not allow for elevation of the body part being treated & an increase in edema may occur.

Care should be taken to ensure that the patient is in comfortable position during the treatment.

With immersion method, the temperature elevation of body tissue is 2c higher then dips method

DIP & WRAP / GLOVE METHOD: It provides mild heating. It is the most widely used method. This can be used for the extremities Hands, Wrists, Feet &

ankles. The therapists instruct the patient to dip the body part in a bath

and then remove it until the paraffin solidifies and repeated 3 4 times until thin layer of adherent solid paraffin is formed which covers the skin.

It is important to dip the part briefly otherwise the outer most coating is melted off & the thickness of wax does not build.

Dipping is repeated until a thick coat is formed. In other words, at least 8-12 times until thick glove on a part.

Once thick glove of wax is formed the treated area should be wrapped 1st in a plastic bag / sheet / aluminium foil and then wrapped with a towel to assist in heat retention.

If oedema is concerned then area may be elevated to above the level of heart.

The effective duration of this treatment is 15-20 minutes. TOWELLING/BANDAGING METHOD: A lint cloth / towel is immersed in molten paraffin wax and then

wrapped around the body part. Several layers can be made over the body part. This method is preferably used for treating proximal parts of the

body. S8. OTHER PHYSICAL THERAPIES HIGH VOLT THERAPY High Voltage Pulsed Current (HVPC) has been used in therapy for many years (machines have been available since the 1940's), yet while in many countries it is highly popular, in other countries its use is minimal. It is sometimes called 'Twin Peak Monophasic'

Essentially, this stimulation modality employs a monophasic pulsed current, the pulses being delivered in a doublet (hence the 'twin peak' term).

Each pulse is of short duration (typically less than 200s), but, as the name implies, at a high peak voltage (up to 500V, typically 150-500V).

There is an evidence base for its application in a range of clinical presentations, mainly relating to the stimulation of wound healing, pain relief and facilitated edema resolution.

WAVELENGHTS There are several variations on the specific waveform employed in machines from different manufacturers. Some machines allow very little

control over the pulse parameters whilst others enable variation of several key parameters. (A) direct current (B) monophasic pulsed DC (C) symmetric biphasic pulsed (D) twin peak monophasic USES:

There are several key areas in which high volt is employed clinically.

The main two of these are for Wound Healing and Pain Management.

Additionally there are applications which have been advocated (and researched to a limited extent) for edema Management and Muscle Strengthening. WOUND HEALING

A trial concerning the effects of High Volt was reported by Kloth and Feedar (1988).

A group of 16 patients with stage IV decubitus ulcers were recruited for the trial and all had lesions that had been unresponsive to previous treatment.

All patients in the treatment group achieved complete healing of their ulcers (on average over 7.3 weeks at a mean healing rate of 44.8% per week). The control group patients did less well, with an increase in mean wound size of almost 29% between the first and last treatments.

PAIN MANAGEMENT There is generally less evidence available relating to the use of HVPC as a pain management tool, though it is certainly practiced (i.e. supported by the anecdotal evidence). MUSCLE STRENGTHENING There has been a range of research over the years looking to see if muscle strengthening can be achieved with EStim - ranging from Interferential therapy, through Russian Stimulation to NMES based interventions.

High Volt has a varied popularity around the world, with pockets of high activity, and areas of minimal or even absent use.

It does have an evidenced efficacy, though at the present time, this is most strongly associated with wound healing activity.

It has been evaluated for pain relief effects, muscle strengthening and edema management, all of which has some supportive evidence.

Microcurrent (MENS) Microcurrent Electrical Nerve Stimulation Microcurrent therapy is the use of small amounts of electrical

current (measured in millionths of an amp) to relieve pain and speed healing in the soft tissues of the body.

Injuries disrupt the bodys normal electrical activity. Microcurrent therapy aims to create electrical signals similar to

those that occur when the body is repairing damaged tissues, to promote the healing process.

Microcurrent therapy uses amounts of electrical current so small that the patient usually cannot detect it

USED TO TREAT Blood circulation Range of motion Muscle spasms Muscle atrophy Venous thrombosis Nerves and muscles damaged by accident or injury Each tissue type in your body has its own signature electrical

frequency, which may be disrupted by injury or disease. Microcurrent therapy simply restores normal frequencies within

the cells, resulting in remarkable improvements in pain, inflammation and function.

At the cellular level, microcurrent therapy stimulates a dramatic increase in ATP, the energy that fuels all biochemical functions in the body.

It also bumps up protein synthesis, which is necessary for tissue repair. The ensuing enhancement in blood flow and decrease in inflammation translates into reductions in pain and muscle spasms, as well as increased range of motion.

Unlike TENS, russian, IFC etc, which also use electrical currents to relieve pain, microcurrents are so weak that they dont stimulate the sensory nerves, so the patient should not feel no shock-like sensations.

It does not reduce muscle spasm, stimulate denervated muscles or cause muscle contraction

INDICATIONS Wound healing Reduce inflammation and edema Acute pain RUSSIAN Essentially, this type of electrical stimulation employs what is

referred to as a medium frequency alternating current (in the low kHz range - thousands of cycles a second), which is delivered in a pulsed (or burst or interrupted) output.

The pulsing or bursting is at a 'low' frequency, and as a result, nerves will respond. It is primarily employed as a means to generating a motor response

It was developed for Russian elite athletes to increase muscle strength

It will increase strength in a deconditioned person May have benefits with scoliosis to strengthen the stretched

convex side musculature (stretch weakness) The 1971 Russian experimentation set out to establish the

fundamental principle of this stimulation method. The timing (stimulation/rest/repetitions) protocols were

considered as was the issue of treatment frequency. What has become known as the 10/50/10 protocol was identified

as being effective (this essentially means stimulating for 10 seconds, leaving a 50 second rest period and repeating this sequence for 10 minutes (i.e. 10 stim/rest cycles) was indeed effective.

The stimulation was found to generate fatigue if delivered for more than 10 seconds (at maximal tolerable intensity). Various interpulse rest phases were tested ranging from 10 through to 50 seconds.

The mechanism of the increased force generating capacity of the stimulated muscle was attributed to both a short term CNS adaptation and also to an increase in muscle tissue volume

Russian Stimulation (at 2500Hz or 2.5 kHz) has been shown to be effective in increasing muscle strength and torque generation.

Useful in denervated and debilitated muscles HOW TO USE IT Pad placement on muscle belly Strong motor contraction needed 5 consecutive days with 2 days rest Continue regular workouts. Always workout before stim