PCE StudyBuddy
Day 17 AM- MODALITIES 1
Things to read before the class-
Modalities:
Ultrasound:
High frequency alternative current- electrical current to mechanical
(sound waves)
Piezoelectrical properties- head of ultrasound has traducer- it has
crystals- on current- the crystal property is compression and relaxation
(refraction)
Compression (tissue compressed- high intensity) and refraction (tissue
relaxes- decrease intensity ) material – when the waves goes in tissue- it
also lead to compression and relaxation
Parameters:
Frequency Deep(1 Mhz)
superficial (3 Mhz)
Intensity 0.1- 3w/cm2
Mode Pulse
Continuous
Effect Thermal- more dan 1 w/cm2, continuous
Non thermal- 0.1- 1 w/cm2, pulse, 20 %
duty cycle (decide on time of injury)
Duty cycle On time/ on+off time x 100
Continuous on and off time
Duration 5 to 10 mins
Q&A
Pulse at 1 msec and total pulse period at 5 msec, what’s duty cycle
Ans: 1msec/1+4 x 100= 20%
Appropriate mode to treat supraspinatus tendinitis-
Ans- acute (active inflammation)- non thermal effect, chronic (is 2 type active
inflammation, no inflammation)
1 Mhz, pulsed mode, intensity of 0.5 w/cm2 (tendon is deep so 1 Mhz)
How to decide duty cycle- nonthermal effect- 20 %
Soft tissue Delayed tissue
shortening( contracture/ healing(inflammation/
tightness ) chronic condition
Effect of US Thermal Non thermal
Duty cycle 100 % 20%
Depth of 1-2 cm More or equal 1-2 cm More or equal to
problem to 5cm 5cm
US frequency 3 Mhz 1 Mhz 3 Mhz 1 Mhz
Ultrasound 0.5 W/cm 2 1.5- 2.0 W/cm2 0.5- 1.00 W/ cm2
intensity
Duration of 5- 10 min/ 2 x ERA
treatment
Note- why 20 % duty cycle- research stays 20 % is idle for non thermal effect.
Q&A
Carpal tunnel syndrome, ultrasound dosage ?
Ans- Pulsed mode, frequency 1 Mhz, intensity 1 W/cm2
Recommended Rx-
Continue US adversity impact nerve conduction, velocity coz of our healing,
Pulsed US (non thermal effect)
1 Mhz freq- 1.0 W/cm 2, intensity or less pulse 1:4, 5cm2 transducer, 5 mins per
session
Along with wrist splint
Duration and area:
If area is 20 cm2- head size should be 10 cm2- 5 to 10 mins
If area is 40 cm2- and same size size head than extend the duration of
treatment (divide body part into 2)- 10 to 20 mins
Intensity and time
Treatment time should be increased when lower intensities or lower
frequencies of US are used
Goals to increase tissue temperature
1.5W/cm2- 9 mins
2 W/cm2- 8 mins
0.5 W/cm2- 10 mins
Moving head
Normal speed- 4cm/sec (2- 8 cm/ sec)
Thermal effect- if slow- more heating at the center- absorption-
overheating- burn
If fast movt- poor heating or poor absorption
Non thermal effect- standing waves- damage the endothelial lining of blood
vessels(statis of blood vessels)
Indication :
Soft tissue shortening- immobilisation, spasm, contracture- with ultrasound-
thermal effect- if stretching is given tighter can improve shortening
Pain control- improving blood supply
Soft tissue healing
Tendinitis and inflammation
Fracture- 1st 2 week post fracture(inflammatory and proliferative stage )
Increase rate of healing, accumulate bony union
0.2- 0.5 W/cm2, 20 % duty, 5 mins, 4 times week/ low dosage, no
high dose
Growing epiphysis- very low dose can be given- no high dose
Test the fracture with ultrasound:
Immersion method (water is coupling medium)- to irregular area eg. Thumb-
1 cm awaz from area- so that water acts like a medium like gel
Plastic, ceramic and rubber bucket- rays are evrywere in the water , waves
will reflect back and intensity will increase.
How to assess stress fracture:
Water coupling media, 1 Mhz, continuous mode, 0- 2.0 W/cm2
Pressure acting (coz crack bone, strong intensity it starts to vibrate, so
deep acting pain), bruising at the end of fracture.
Once you increase the intensity 1 to 1.5 W/cm2- patient any feel the pain
Q&A
Contraindication UST around hip joint- THR 6 mnths back
Ans- metal (precaution – not contraindication), plastic (complete
contraindication )- if used non thermal effect
Chronic condition- 6 months back- so thermal effect
Contraindication:
Tumour- on the site and around that area
DVT- massage effect- embolism- pulmonary
Pregnancy- hyperthermia- damage the growth of featus- around the
abdomen, lower back, pelvis- LIPUS- lower intensity pulsed ultrasound-
fetal growth will be impaired.
Reproductive organs- cause infertility- kills gammot cells
Eyes
Joint cement- methyl methacrylate (material used for cementing)- its plastic-
break, loosen or melts
CNS- no directly on structure- eg. Laminectomy- removal of lamina- spinal
cord is exposed- so no UST.
Precaution :
Metal/ plastic implants- thermal effect proximal to area, increase blood
circulation and blood flows down
Acute inflammation- non thermal effect
Chronic inflammation- Thermal effect
Fracture- immersion
Breast implants- silicon gels- burst or melt
Epiphyseal plates- burns
Issue with ultrasound:
Warmth not felt
Feels not at skin surface
Cavitation (non thermal)- gas filled bubble- stable- normal compression/
refraction, unstable – gas can be filled in between compression and
refraction and burst.
Coupling medium- more-can lead to burn, less- can lead to air bubble
Q&A
UST- 1.4 w/cm2, 3 Mhz, after 2 mins, pt complains of burning effect, what
to do
Ans- not to change to pulsed mode- coz it will give non thermal effect
treatment with reduced intensity(if still complains of pain or burning than
discontinue it)
ELECTRICAL STIMULATION
Electrode 1st- motor point(sup. Locatn of motor nerve)- it will
placement produce greatest contraction with least amount of
electrical current
2nd- point were the motor nerve enters the muscle
Modes Continuous- to improve strength
Interrupted- to prevent fatigue
On & off time –
1:1, 1:2- to relax muscle (eg. Spasm)
1:3, 1:4, 1:5- muscle contraction- to increase strength
Eg- 2+/5- 1:5- more relaxation time
4+/5- 1:3- less chance of fatigue, given wen muscle is weak to
give strength it
Ramp To make onset of stimulation more comfortable for pt
Gradually increase and gradually decrease
Avoid quick stretch
2 sec ramp on, 6 sec on time, 2 sec time down
Parameters 1. Pulse & pulse duration- 125- 350 msec
125-200 ms – small muscle
200-350 ms- large muscle- eg. Quads, gastro, hams, Gmax
1 pulse- 1
contraction- ms Pulse duration- duration of one pulse- current flow in any
twitch direction
2. Phase and phase duration- current flow in one direction
3. Amplitude or intensity- max value of current or voltage
35 pulse- will
4. Frequency ( pulse per second- PPS)
combine give
20-30 pps- small muscle- eg. Facial , lumbricals
big ms
contraction 35- 50 pps- ideally recommended- 2+ MMT
50-80 pps- later satge for strengthening- 4 or 4+ MMT
5. Treatment time
Ideally- 10-2
0 min for 10-20 contraction
Can go upto 30 mins
Waveform Direct current- used in iontophoresis
Alternative current- pain control and muscle contraction
Pulsed current-
Biphasic- 2 phase- amnt of current can be different or
same, symmetrical and non symmetrical
Application- Eg
Freq Pulse Intensity On:off Ramp Treatment
duratn time time
Muscle 35-80 pps 200- Depends >=1:3 Atleast 10- 20
strength 350msec 2 sec mins
Q&A
Pt for E- stim at upper trapezius- spasm after heavy lifting
Ans- 40 pps freq, 130 ms, 1:1 duty cycle for 15 mins
Spasm – muscle over working
Uppr trapezius- small muscle (not whole trapezius)
350 msec – large ms, 120- 130 msec (small)
Spasm – too much work already going on- so fatigue in muscle- 1:1
1:5- longer relaxation- to strengthen the muscle
1:,1, 1:2- to decrease the overactivity of muscle- calm it down
Edema leg- e- stimulation- parameter
Ans- 1:1 or 1:12- ideal for edema- 35 pps, 2:2 on :off, 250 msec, 30 mins
Ideal recommendation- 35-50 pps (nothing to do with freq and large muscle)
Leg longer muscle- so higher pulse duration
if Longer break- fluid will come back
stimulation should be given in elevated position
Pt spasticity of wrist flexors, therapist wants to strengthen wrist extensors-
protocol ?
Ans- 35 pps, 10-40 on :off, ramp > 4sec
Spasticity of flexors- means antagonist is weak (so no 1:1, 1:2- don’t want
to fatigue ms)
Only Spasticity – should be ramp 4-8 sec
