Hot pack:

Introduction

Explain the effects: hot pack to improve your blood circulation/flow and your tissue extensibility

Before I begin I need to ask you some questions to see if you’re suitable for this treatment:

Have you ever done such treatment before?

Any open wound?

Any skin problem?

Any circulatory problem (over lower back area)?

Any heart conditions or diseases?

Any inflammation?

Any tumor?

Do you have any medical condition that I need to know about?

Looks like you’re good to go for this treatment, next I’ll need to do a skin sensory test to see if your
skin is suitable for this treatment

Ok so now I’ll proceed with the thermal sensation test – this test is to determine if your body can
differentiate between hot and cold surfaces

This is an example of a hot surface, and this a cold one

Can you tell me what is this? Hot, cold etc

Next we will proceed with doing this test (thermal sensation test) on your (e.g. lower back), do you
mind if you lie down on your stomach

Do you mind if I lift your shirt up a little?

Ok can you tell me what is this? Hot, cold

Ok looks like your skin is just fine for this treatment, next I’ll proceed with the treatment

Ok just to explain the purpose of the treatment again, it is to improve your tissue extensibility and
improve your blood flow

Initially you may not feel any warmth or sensation but throughout the treatment you should feel a
mild comfortable warmth, it is not always the hotter the treatment the better the therapeutic effect
so you should not feel any heat concentration at any parts of your body, so if you feel any
uncomfortable sensation do inform me immediately if not you will have a risk of getting burnt

This treatment will last 15 mins, when I position you to start the treatment do not move at all

Do you understand what I’ve just explained to you?

Ok good lets proceed with the treatment
Hot pack – 8 layers of towel

Check baseline pain level and functional ability before the treatment

Now I’m going to apply the hotpack, is it ok if I lift up your shirt slightly?

How do you find this position? (is it comfortable?)

I’ll leave this here (hotpack) for 15mins, do inform me if you feel any uncomfortable sensation

15mins later:

Ok the treatment is done already, please don’t move while I help you remove the hotpack

Ok can you help me sit up (patient in lying prone)

Actually there is some redness on your back, but it’s a normal response so don’t worry about it

How do you feel now?

Is there any difference in the pain?

Ok so that’s all for today’s treatment, I’ll check with you the next time we meet again
Cold pack (on thigh – patient in supine):

Ok now we’ll proceed with the cold pack treatment

Do you mind if pull your shorts slightly?

For this treatment you will initially feel abit of cold, but after awhile about 2-3 minutes later you’ll
get used to it

If you feel any extreme cold or uncomfortable sensation do inform me immediately

This treatment will last for 10mins

Ok that’s all

Skin sensation test – to ensure you can differentiate between sharp and blunt point

Can you tell me what is this? Sharp, blunt

Now I’ll do this test on your lower back.

Looks like your skin is suitable for this treatment, so we will proceed with this treatment
SWD: Treatment frequency for SWD = 27.12MHz, so high frequency not enough respond time for
nerve or muscle to respond to stimulation

Requires wooden plinth and no metals around so that it is safer to be applied by therapist. Patient
cannot lie on metal plinth when you apply SWD because of the chances of heating up the metal

Know the Safety aspect of using the machine and operation

Clinical reasoning why you want to choose this machine

All the different procedure to ensure that it is safe for use

Why do you use this machine?

Can you tell me the contraindications?

Can you tell me what it is used for?

Why do you choose this plode? Why did you choose that plode?

How do you position the patient when you do this treatment?

Operation:

There are 2 switches behind

Circuit breaker – when circle and dot together, circuit is closed. (machine is on) When circle and dot
is apart means the circuit is open. i.e. make sure the circle and dot is together, otherwise it doesn’t
work

Power switch – turn on

Press the timer switch (plus / minus) – machine will be on standby, you will hear a sound

Orange light means that there is no electromagnetic wave – As long there is orange light, nothing is
happening, because the circuit is not closed (i.e. it is open), there is no electromagnetic wave

Once timer goes to 30, it will reset to 0

The switch on the left, is to switch between continuous and pulse. For pulse I can choose different
frequency. The higher the frequency, the closer it is to being continuous. There is 2 readings here.
The numbers here are recommendations for circuplode and flexiplode, follow the recommendations,
don’t turn all the way. CPL stands for circuplode, FPL stands for flexiplode. When you fix the
circuplode onto the machine, the number here says 6, so try not to go to 10 because the circuplode
will be under a lot of stress and may sometimes spark, and have burning smell coming out.

i.e. limit for circuplode is 6, limit for flexiplode is 7

How to turn off the machine?

Turning down the intensity to 0 with the timer running does not turn off the machine, the timer
must be put to 0, so increasing it after 30 it will go down back to 0. I.e. to turn off the machine, put
the timer back to 0

Don’t let cables touch each other – if they come in contact, that area will have accumulation of
electromagnetic wave, and will heat up
Different plodes:

Metal plate/diplode – used for contraplanar setup – to have the capacitive effect of electromagnetic
wave going through from end to the other end. Usually placed to the joint or any other structure
that you want EM wave to pass through and heat up the tissue. It will heat up anterior and posterior
depending on how you place it. There are different sizes (3 sizes): big and small and even smaller.
Choose the size based on the area you’re treating (for e.g. someone with a big knee, you would use a
bigger plode so that it covers the entire knee. If you’re treating a wrist, use a smaller one). The size
ideally should only be slightly bigger than the structure/area you’re treating. If you cannot have a
perfect fit, go for something bigger rather than smaller than the treatment area.

Flexiplode(FPL) – works on a co-planar concept, the 2 planes are side by side. You must open the
plane

- Electromagnetic current forms a rainbow

Circuplode (CPL) – have pulsed mode also. It does not use capacitive method of inducing EM wave to
heat up tissue, no 2 plates, it does not use electromagnetic wave. It uses induction, which uses eddy
current. Don’t go above 6, it will not light up with the stick/neon tube because there is no
electromagnetic wave. Place on the skin as close as possible, about 2cm away from skin

For both flexiplode and circuplode about 2cm away from skin. The distance will always be the same
no matter if you put continuous or pulsed.

Secure the plodes

If you want to move the arm, unlock the knot first before pushing

Which plode to choose?

Metal plate- Anterior posterior or sideway, it passes through the body. Using this allows you to heat
up both sides

Circuplode – heats up only on one side, use for a big area you want to treat like lower back, get
patient to lie prone and put this on top. Allows you target large area easily

If you have a big patient, you can use this for the thigh, or shoulder.

You cannot use one big and one small, because there will be more concentration of electromagnetic
wave on the smaller end, which will result in the part infront of the smaller plate heating up more.
Normally you don’t do this, but if you want to then you must have a reason why you want to heat up
this side more ( for.e.g. if the bruising is concentrated on one side but the other side is not so
painful)

Flexipad – functions like a electrical hot pack. People can lie on top of it. This is used mostly in co-
planar format with a gap between these 2 flexipads to ensure that the rainbow is large enough, too
close the rainbow will be very small = no treatment. Electromagnetic wave is like a rainbow, it comes
up and patient lies on top
Heating effect of using pulsed is much less – however pulsed is still used for tissue stimulation for
healing

2 Towels

Patient has low back pain – sub acute stage, pain is his main concern I want to make him feel better
because I find the muscle very tense, relaxation of the muscle will probably result in him feeling less
pain

I decided to use SWD to treat your back. In order for me to treat you with this machine safely, I need
to check some contraindications which is important for you to be safe

Any treatment you want to do for your patient, first thing you do is assess what is wrong with them

1) Assess your patient’s condition and determine what physiological responses you want (pain
relief (you can use heat, ice, massage, IF therapy), reduction of swelling (to reduce swelling
you won’t use heat but ice), make muscle relax, increase the range, or you just want patient
to feel comfortable
2) Can the machine apply heat safely for the patient? If it can, then think about the
contraindications
3) Contraindications (can the patient receive treatment safely):
1) Any metal implants
2) Any cancer around that region
3) Any skin condition, circulation problem?

Sample:

Patient has low back pain – sub acute stage, pain is his main concern I want to make him feel better
because I find the muscle very tense, relaxation of the muscle will probably result in him feeling less
pain

I decided to use SWD to treat your back. In order for me to treat you with this machine safely, I need
to check some contraindications which is important for you to be safe

Contraindications:

1) Do you have any metal implants in your body

2) Do you have a pacemaker
3) Do you have any circulatory problem that you have been diagnosed before?
4) Do you have any skin sensory changes, like you can’t feel a certain part of your body, like
numbing sensation?
5) Do you have any recent infection that you know of?
6) Are you currently having any fever?
7) Have you ever been diagnosed with cancer before, around the region which i’m going to
treat which is your lower back?
8) Do you have any open wounds on your back? Or open wounds on your skin?

It seems that you don’t have contraindications for this treatment, but I need to do a skin sensation
test for you. The skin sensation test for this machine is hot cold. Just to make sure that you can feel
the difference between hot and cold
Use 2 testtube, one hot water one cold water. Test on a good side first then the affected side. So for
lower back pain I will test on the leg first for e.g then on the lower back

Once done, patient is normal in terms of sensing hot and cold

Ask patient to wait while you setup the machine : test the machine and putting the equipment nicely

After setup, ask patient can you lie down for me, put a pillow underneath his knee

Before I start, there is a warning that I need to give:

Tell patient what treatment you’re doing

How long is the treatment

What you should feel during the treatment

What you should not feel during the treatment

If you feel something that you’re not supposed to feel, what are they supposed to do?

And some precautions, in regards to whether they can move, touch the machine, metal.

And finally ask them:

Do you understand what I’m saying?

Any questions?

Can I proceed?

If they say yes then you can turn on the machine

 Always think about the safety aspect for the patient (putting hand on chest because wires
are close, tidying up the wires so the wires are close together and not all over the place)

Sample:

I’m going to give you Shortwave diathermy treatment and the treatment will last 20 minutes. During
this 20 minutes what you should feel is mild comfortable warmth (Where? On your lower back). If
you feel heat concentrating on one spot or you feel is very uncomfortable, it is too hot, you may be
in the danger of being burnt. When you feel that, I need you to call me, I need you to ring the bell
and then I’ll come to assist you. Please do not move, do not touch the equipment, don’t sleep and I
need you to hold your hand up on your chest because the wire is very close to you. Do you have any
metal on your body, I need you to remove it now, your coins, your keys or whatever in your pocket,
hand it to me I’ll put it somewhere for you. (Because there are a lot of hidden metals on the body
that the patient may be unaware of, e.g. piercing on belly button, tongue piercing, braces, spectacle
made of metal, earrings, necklace, belt buckle, if you cannot ask patient cannot remove (like braces),
then too bad you have to use other modalities instead like hot pack) During this treatment you’re
not supposed to use your handphone (due to the electromagnetic wave, it is advised that you do not
use your handphone during the treatment). Do you have any questions? Do you understand what
I’m saying? Can I proceed?

Operational:
First time doing treatment for patient, don’t go above 50 (there is 0, 50, 100 marking). Higher is not
better. Check on the patient about every 5 mins if this is the first time you’re doing this for your
patient, just to find out how do you feel? Is it it too hot? Is it comfortable? If its too hot, reduce. If
patient says he does not feel anything, I’ll make sure the connections are correct, and there’s no
orange light. If patient don’t feel anything, I’ll increase slightly and see how it goes

After I’ve done the treatment and the treatment is over:

Turn off the machine, make sure the timer is off. Then remove the machine

After turning off the machine, there might still be a little bit of electromagnetic wave out there,
orange light can’t pick up, there’s so little EM wave. IF timer is OFF, the machine is confirmed off

Ask for pain score

Last thing you do: Check the skin of the patient (by visually seeing and asking the patient), whether I
burnt the patient (i.e. make sure the patient is not burnt), whether there is redness or bruising

Explaining the procedure to the patient:

SWD to heat up the area to relieve the pain

Patient asks you how does this machine help with relieving my pain?

There are many ways you can explain:

Increase blood circulation, wash away the pain that is irritating your joint

Or you can explain Pain gate theory to your patient in a way they can understand

Or Pain relief phenomenon from downregulation of pain (by inducing abit of pain which will help to
reduce pain in the body by stimulating some of the nerve fibers causing the body to release
endorphins in the spinal cord level) – i.e. it is like pain until numb, b/c your body downregulates pain
Can you create pain a way that is controlled, tolerable, but still causes that numbing effect
ESWT does not downregulate pain – it causes microtrauma to restart the inflammation

IN summary:

Find out what’s wrong with the patient, and determine which equipment is suitable : this is the
clinical reasoning part, what you want to achieve physiologically

Check contraindications

Check Skin, sensation test

Setup

Give warning before you start

Electrical Stim:

Machine > click on electrotherapy > go to Interferential (IFC) > click edit > leads to page where you
can change the setting of IF current therapy

Different machines have different parameters that you can adjust. Not all parameters can be
changed.

Sweep:

This machine you can change the sweep to on or off. Sweep off means that you have a fixed beat
frequency of 100Hz. You can change the beat frequency as well to like 50Hz or whatever. If you put
sweep on, then you have a low and high range for beat frequency (for this machine low is set to 80,
high is 150Hz, 1 channel will be 4000Hz while the other channel will move between 4080 to 4150Hz)

Beat frequency:

The beat frequency is the resultant actual treatment frequency that you’re treating with

Carrier frequency:

The reason why you need 2 carrier frequencies instead of just using 150 Hz to treat is because higher
frequency allows for deeper penetration, and this higher frequency also reduces the stimulation of
the sensory nerve on the skin (making it more comfortable for the patient). Because the higher the
frequency of the carrier frequency, the less sensory stimulation you have on the skin (the machine
can go from 2000 to 10000Hz for the carrier frequency. Also the modulation occurs under the skin

Vector scan:

Vector scan = you can set to manual, or 100%. Flower represents the 2 different channels current.
The flower is where the modulation of the current will occur, i.e. it means the treatment area. You
want the flower to cover the parts you want to treat. You can change the vector by adjusting the
angle. Purpose? If you know where is the nerve or structure running, then you can adjust the current
to be aligned with that so that you get maximal stimulation over that region. I.e. vector scan allows
you focus the treatment on a particular spot

CC/CV: (some machines don’t have this function)

Constant current or constant voltage, if you want to stimulate a nerve then you use CC. If you want
to stimulate muscle you just CV

Treatment time: adjust accordingly

Setup:

On top there are 2 holes, channel 1 and channel 2. Below is channel 3 and channel 4. You can
connect 4 connectors. For each patient you only use 2 channels. So 1 machine can simultaneously
treat 2 patients
Equipment:

- Rubber pad goes inside wet sponge

- Sticky pad – make sure you criss cross the pads
- Suction cup

1st step in any modality you want to do for your patient is assess your patient, ask them what’s
wrong to identify what is their problem.

2nd step, is ask what modality can I use to complement my treatment and help this patient?
If patient’s main problem is pain, then you would be thinking of modalities that can relieve their
pain. Ask yourself, what sort of pain is the patient experiencing? Is it pain due to an acute situation?

Sample case:

e.g. patient fell down, twisted the knee, ligament strain and knee is swollen, happened just
yesterday from playing basketball.

Patient comes to you, presents with restriction in movement, painful and swollen knee. What can
you do to relief pain?

What modality can you give? Definitely not hot pack. Although hot pack can relief pain, you don’t
want to induce more swelling in the joint.

1) Cold pack
2) Pulsed Ultrasound – stimulate the ligament cells for healing
3) Pulsed SWD – use for healing stimulate the tissue
4) TENS or IF – for pain relief

I’ve decided to use IF for treatment. Reason why is because patient has pain. My main purpose is to
reduce his pain, and since there’s some swelling, if I can get the muscle to contract I may be able to
remove some of the fluid around that region.

After you say I want to use this machine, the examiner will ask you can you explain to me how this
machine help relieve his pain?

2 Main concepts of pain relief:

1) Pain gate theory – stimulation of A-beta sensory nerve fibers. The sensory nerve fibers being
stimulated will block some of the signal coming from the pain receptors/fibers going up to
the brain. The stimulation of a lot of A -beta nerve fibers being stimulated in that region, the
signal goes to the same level of the spinal cord that is receiving pain signal from the knee,
which blocks some of the pain signal going up to the brain, so the patient feels less pain
2) Downregulation – works by stimulating pain receptors, patient has pain, so you use some
electrical stimulus like TENS or IF. If you turn it up high, patient will start to feel muscle
twitching, and feel abit of aching and pain sensation. That’s when the A delta nerve is being
stimulated. With additional pain stimulus going up to the brain in a controlled way (not too
much pain to patient until they want to cry), i.e stimulate the A delta nerve that send pain
signal up to the brain, the brain will receive the signal and downregulate the pain.
How the brain the does that is that there is an area in the brain called periaqueductal grey
matter/area, once the pain signal goes up to the brain, it will send a signal down to the same
 level of the spinal cord to release encephalin which works like a numbing effect around that
region so that you don’t feel so much pain
Once the pain is downregulated, any other pain that I create on you you don’t feel it
anymore. Like if I pinch you its not so painful anymore

The next thing you want to do after deciding to use IF is to check for contraindications

Contraindications:

1) Superficial metal or on the surface

2) Hypersensitive to stimulation
3) If patient has loss of sensory sensation to that area (Do a skin sensation test and if they
cannot tell then its not a good idea to do this treatment)
4) Pregnancy (any treatment around the abdominal or pelvic region is not ideal), but you can
still treat the shoulder, knee or ankle for pregnant woman.
5) If patient has history of current cancer around the region that I’m treating
6) Younger patient that is still growing, any treatment around the epiphyseal growth plate you
have be careful, try to avoid if possible
7) Patient with pacemaker and you want to treat around the chest, is a contraindication
8) If patient does not have pacemaker but have cardiac arrythmia, don’t treat around anterior
chest wall

Next is skin sensation test (no heating element so no need hot cold)

Do sharp blunt to test for pain, because this machine will produce some pain sensation, patient has
to be able to tell if its too much pain. Test on unaffected area, make sure patient understand which
one is sharp and which one Is blunt. Ask patient to close eyes and test on area you want to treat (no
need to go all over the place)

After clearing the skin sensation test, I will setup the machine and test the machine, then give the
warnings and start the treatment.

How to test the machine? For the machine test, there’s no diagnostic device that you can plug in
that says that the machine is working. So you test on yourself, test for current.

Take 2 towels, 1 towel put on the pillow (b/c no pillow case)

Ask patient bend knee, put pillow below

If patient got broken skin, its not a contraindication you just avoid the area

After everything has set up, I give the patient a warning

Warning for patient:

I’m going to give you IF therapy treatment for your knee. This treatment will last for 20 minutes.
During this 10 mins you will feel a mild tingling sensation around the muscle and you will also feel
your muscle twitching. If you feel the stimulus is too strong, if you feel uncomfortable or if you feel
pain let me know, because there may be chance of skin damage if it is too strong. During this
treatment, please do not move the electrodes nor turn off the machine, and do not sleep. If you
want to use your handphone you can use your handphone (using handphone is very subjective,
some places cannot use. If you worry the machine might be interfered by the electrical signal of the
handphone, then don’t let patient use))

Do you have any questions?

Do you understand what I’m saying?
Can I proceed?

Ask patient to tell me when they first feel something in their knee. (when you reach a certain
threshold the nerve will fire). How high you should go? Once patient is able to feel something, then
you double of that intensity. ( but not always you can double)

If electrodes drop off the machine will say poor contact

Start the treatment timer

Once treatment is over, check patient’s skin condition. Whether there is any redness, bruising or
tear on the skin. Next you check pain scale, to see if patient has improved

Suction machine has no current going out, unless you connect the cable which will link the top unit
to the bottom unit. Now the current from channel 1 and 2 will divert to the bottom and come out
from the suction machine

Knob to adjust intensity of suction power

Suction cup works by creating vacuum which allows it to stick onto the patient. Putting on the
patient for too long will create a little bit of a bruise which will disappear

So when you use suction cup you tell the patient in the warning: There will be a bit of bruising when
I use this, it is normal it will go away, are you ok with this?/ The suction cup will leave a mark, b/c we
are going to do for 20mins

Once suction cup is on, you can adjust the pressure

If patient feels tingling sensation with no pain or muscle twitching, then you’re only stimulating A
beta nerve which helps with pain relief. For all electrical stimulation if you up higher, patient will
start to feel muscle twitching. This is when the motor nerve is being stimulated. Next is the pain
nerve being stimulated. Increasing further increases the pain threshold. Going higher will stimulate
denervated muscle

So if patient has nerve damage to the muscle (muscle doesn’t move). If you try to stimulate the
muscle the patient will feel pain first before you start to stimulate the muscle. And therefore this is
not a worthwhile treatment. But if the nerve is not damaged, e.g. patient has stroke, nerve is still
intact just the brain cannot control, then you can do this and stimulate the muscle to contract. But if
the nerve is degenerated, and you want to stimulate the muscle, you going to stimulate pain to the
patient first
Therefore if muscle not working it does not mean you use NMES. Denervated muscle is not a
worthwhile treatment.

Metal implant is a precaution if the metal implant is deep in the body. For e.g. metal on femur, I
want to treat proximal part of quads is still ok for this machine. But if the metal is superficial then

you cannot do it. Chain, necklace, or external fixator or any other metal you can see on the surface
then you cannot do it over that region. Collar bone fracture and metal is superficial then don’t use
this treatment.

In electrotherapy section there’s a lot of settings.

Intereferential : 2 modes

4 hole(Typical interferential) : use 2 channels, there is interference between the 2 channels to create
a new frequency for treatment

Premodulated setup: uses 1 channel so only 2 holes. Not considered as interferential because there
is no interference between 2 different channels, it is just one channel that is pre-modulated.
Pre-modulated meaning the system somehow modulates within itself to create the current.
This premodulated setup is more like a TENS with a IF frequency. This machine can go up to
1000Hz

TENS machine have working frequency up to about 300Hz (can go at most up to 300Hz). At 300Hz if
you put onto patient, you get a contraction and you also feel pain b/c there is a lot of
sensory stimulation on the skin

IF is more comfortable and you can deliver the treatment deeper

Microcurrent is for healing injuries and tissues

TENS machine:

Has channel 1 or channel 2

Turn on machine, once you hear a click it is on. Do not keep turning because it’s the same switch for
intensity. Electropads

Press mode: There are different modes

1st mode called B – current given out in pulses

2nd mode called Normal TENS- most typical TENS setup which allows you to adjust frequency,
pulse duration and just the time. The higher the pulse duration, the less intensity you need
to stimulate the nerve (for big muscles, longer pulse duration). Frequency how many pulses
per second (how fast the current is going out per second). Higher frequency you will get
more of a constant contraction – patient will cramp up. Pulsed current allows patient to rest
and not have their muscles cramp up

3rd mode called M – Modulation (go up and down) – you can change the frequency but it will
automatically modulate the output for you

4th mode is SD1 and SD2 - different variations of modulation

5th mode is S – S stands for synchronous

6th mode is A – which stands for asynchronous

A and S mode for NMES

Both these modes have ramp up time, on time and off time settings. If you use these, the purpose is
no longer to relief pain but it is to stimulate the muscle. You want patient to do something
while the contraction is there. (e.g. flexion, extension of elbow, straight leg raise). So, you
tell patient whenever you feel something you lift up your arm, when it goes away you put
down (so that there is a rest).

You must evaluate the strength of the patient using MMT. If patient is grade 2, you tell patient when
you feel the current you try and do the action of the muscle you’re targeting. So you’re
helping the muscle to contract while the patient tries to do the action. i.e. you’re assisting
the patient to work harder.

Don’t do on the chest of a patient with pacemaker

Place the electrodes over the muscle belly. The electrodes should have a spacing of at least 1 electro
pad size apart. Place according to the direction the muscle fibers are running

TENS: some patients may get a little red patch, if you turn up the intensity too high or too long, or
could be allergic reaction. B/c this is not IF, it is working at a frequency that stimulates the
surface skin a bit more. If patient knows that they will have adverse reaction then you can’t
do this treatment
3 different TENS application parameters for pain control:

1) Conventional/Traditional TENS = high-rate TENS – uses pain gate mechanism to control pain
 Short pulse duration: 50 to 80 microseconds (with this short pulse duration, you’ll not be
stimulating motor fibers, but instead will be stimulating A-beta sensory fibers, patient
will say they feel some sensation over the area that I’m treating)
 High frequency: 80 – 130 Hz (pps)
 Intensity/amplitude at sub motor intensity so that you produce a strong but comfortable
sensation (sensory stimulation) only without muscle contraction
 Use modulation to limit adaptation to the sensory stimulus
 Only effective while the stimulation is applied, i.e. pain relief does not have a lasting
effect – hence more effective for acute pain
 Stimulation needs to be applied for 30 minutes at least (can be used for as long as I
want, no time limit)

2) Opioid Release via Low-Rate/Acupuncture-Like TENS

 Low rate because low frequency is used : 2-5Hz
 Long pulse duration of 100-250 microseconds to stimulate motor nerves
 Intensity/amplitude – sufficient to create small muscle contractions (patient gets muscle
twitching)
 Stimulates A-delta nerve which leads to endogenous opioid production and release that
is going to bind to the opioid receptors – cause pain relief by binding inhibiting C fibers
activity
 Pain relief is effective for 4-5 hours after the stimulation ends (it has a long lasting effect)
– because of the effect on the opioid receptors
 Use it for 30 mins but not longer than that because I want to avoid the patient
experiencing delayed-onset muscle soreness (because there is muscle stimulation)

3) Burst Mode TENS

 Stimulation is delivered in bursts or packages
 Stimulates the same opioid mechanism as low-rate TENS but might be more effective
because more current is delivered with each burst.
 2-3 bursts/second Frequency
 So there is a lot of pulses delivered all at once, then a gap then a lot of pulses again
delivered all at once – therefore it feels like low-rate TENS but there is more current
delivered in the burst

NMES for muscle strengthening to improve patient’s function allowing them to participate better in
their life roles:

NMES – we’re trying to stimulate action potentials in motor nerves (shorter pulse duration for
sensory nerves, longer for motor nerves) and get a tetanic contraction of that muscle

 Evoked muscle contractions fatigue more quickly than voluntary muscle contractions
due to preferential recruitment of type 2 fibers that are less fatigue resistant, and
synchronous excitation
  Select stimulation parameters that minimize fatigue:
Frequency of stimulus (pps)
Duty cycle ratio – on:off times
Progressive strength of contraction

Electrode size:
choose a size that is large enough to activate adequate number of motor units while avoiding high
current density and skin irritation (when stimulating large muscle groups like the quadriceps, you
need large electrodes). With a small electrode you will have more current density in one area
Big muscle , use big electrodes
for kids (small electrodes since they have small limbs)

Placement of electrodes:
Place electrodes at motor points (where the nerve enters the muscle). Initially I’ll place the
electrodes on the location on the skin where I think the motor points might be, but if I don’t get a
good muscle contraction then I’ll move the electrode to find the motor point

Monopolar: one electrode over motor point, the other over a remote area just to complete the
circuit. Used for specific small muscles recruitment

Bipolar: the 2 electrodes are closer together, used for specific muscle recruitment
closer interelectrode distance- more superficial current, therefore more activation of sensory fibers
larger interelectrode distance – recruit more deeper lying motor units

i.e. how close I put the electrodes together affect how deep or superficial I’m stimming.

Indications:

1) Muscle weakness – use NMES to increase muscle strength (e.g. post op, after knee surgery
the quadriceps is likely inhibited, estim used to disinhibit the quadriceps by facilitating motor
recruitment, retrain the inhibited quadriceps to fire/ tibialis anterior following knee or ankle
surgery (footdrop)/stimulate the wrist extensors to facilitate motor recruitment of the wrist
extensors for functional movement of the hand )
2) Denervation of muscles – electrical stim can produce contractions at long pulse durations of
at least 10milliseconds (stimulating the muscle directly)
3) Muscle atrophy
4) To improve muscle endurance
5) To facilitate range of motion
6) To enhance motor control (for FES) by facilitating a purposeful movement

Parameters for NMES:

1) Waveform – pulsed current, symmetric biphasic

2) Current amplitude – needs to be a sufficient contraction of the injured limb to achieve at
least 10% to 50% of the maximum voluntary isometric contraction (MVIC) of the uninjured
limb. MVIC of injured limb is going to be different because there isn’t optimal muscle
recruitment, so we want to get the injured limb back up to the uninjured limb
3) Pulse duration of 250- 300 microseconds for effective motor recruitment
400 microseconds for large muscle groups
10 milleseconds for denervated muscle
 4) Pulse frequency : 20 -75 pps for tetanic contraction (strong full contraction)
35-50pps for small muscles (b/c you don’t need much frequency to get to tetany in a smaller
muscle with fewer motor units)
50-80pps for large muscles
Beyond this frequency, results in increase in muscle strengthening but also increases fatigue
If I’m getting muscle twitching but not tetany, that is a sign that I will turn up the frequency
What parameter do you need to change if you’re getting twitching but want tetany? The
frequency needs to be increased
Increasing Frequency enhances motor unit recruitment, however the neuromuscular fatigue
is the limiting factor for how much you can increase the frequency
5) Duty cycle – 1:5 ratio (so10secs on,50secs off to give a 1 minute cycle = 1 contraction per
minute) for a treatment time of 15mins
Purpose is to reduce fatigue (only exception is when you’re doing estim for muscle spasm,
you want to induce muscle fatigue)
as the patient improves their muscle endurance, the duty cycle can be lowered for progress
of the patient’s muscle endurance
6) Ramp time – time in seconds to reach peak amplitude or to return to 0
Ramp up – 1-5secs
Ramp down -1-2secs
Prevents sudden contraction of the muscle with the joints jamming at the end range, so
instead it allows for gradual stretch
Allow the patient to get used to the stimulus
Ramp up time is part of on time
Ramp down time is part of off time

Patient is going to get both sensory and motor responses from NMES, tell patient what to expect,
intensity of current should be tolerable to them but strong enough to recruit muscle fibers. Ask the
patient to report to you what they feel, and whether they are feeling the muscle twitching as you
increase the intensity gradually.

Make sure to pre-inspect the skin to make sure the patient has intact skin and intact sensation

Monitor the patient response during the treatment, and their skin if the patient reports discomfort
(if patient says they feel a burning or stinging sensation under this one electrode, I’ll stop the stim
and check under that electrode)

After the treatment inspect the skin and see if there is any redness, and tell the patient that it should
disappear within 24hrs. If it does not disappear within 24 hours I’ll ask the patient to take a picture
of their skin and let me know.

Why NMES?

It is a common post surgical intervention (increasing patient’s strength after surgery- Acl
reconstruction, TKA/or non surgical management for other knee conditions : osteoarthritis,
rheumatoid arthritis, patellofemoral syndrome-strengthen VMO to treat patellofemoral syndrome))
because the patient muscle performance is inhibited, or the patient cannot maximally recruit motor
units voluntarily so NMES can be used to enhance muscle force production

ESWT:

Very expensive machine - $40000

Used for soft tissue, don’t do on bony surface

Inflicting some sort of pain

Electromagnetic current that is created, will force a metal rod in here to move. The metal
rod hits on the applicator in front which produces a shockwave. The shockwave given out is
not focusing on a certain area, it’s a wide spread of shockwave, called radial shockwave.
Radial shockwave, which is disperse of energy is safer than ones that are focused on one
spot. This machine is electromagnetic, there are other systems that use compressed air
pressure.
ESWT has a lot of preset protocols, (preset by manufacturer no studies done).

Why you chose this treatment? B/c it is a chronic condition, that is a tendon or vascular related
problem. It has been there for a while, patient has been going for some treatment or
exercises but it doesn’t heal very well/recover fully. Everytime the patient does something it
hurts

ESWT creates microtrauma to that area by using shockwave and that will kickstart another
inflammation process. But this inflammation process is a controlled one that is very specific
to that area, which will help to restart the healing process (which has probably freezed)

The pressure from the shockwave generates gas bubbles that will burst and create microscopic high
energy water jets, that will stimulate the surrounding tissue and will also increase tissue
temperature. (microtrauma because damage to some of the cells from the impact of the
shockwave)

But because there is also pain created for the patient, you downregulate the pain, after a while
patient may say I’m numb I don’t feel anymore pain, which can also happen

Parameters:

Shocks number: each treatment 1000 to 2000 shocks

Frequency: 2 to 10 Hz (higher frequency more uncomfortable for patient)

Intensity (turn up the bar) – higher the more uncomfortable/more impact patient will feel – use 2
bar/0.28mJ/mm2

If you want to adjust parameters (if patient says its too painful), keep intensity fixed, then adjust
frequency first (reduce the frequency from 10Hz to 5Hz). If its still painful for the patient,
then I’ll adjust the intensity by adjusting the bar from 2 to 1.5

The energy refers to the intensity: 60 mJ?

The intensity is given in bar: 1.5, 1 bar 2bar etc

The frequency refers to the number of hits per second

Set the target number of hits by adjusting the knob (For most treatment 1500 – 2000 hits is
sufficient)

Put gel on top the head, so that it is a bit easier to move around the head and also for contact wise
there is better transmission of shockwave energy

Contraindications:

1) Don’t do on epiphyseal plates for children

2) Fracture
3) Broken skin
4) Cancer
5) Cannot put near neck (b/c impact can rupture the vessel)

Warning:

When I give you this treatment, I’m going to create a little bit of pain around that region. If the pain
is too intense, if you cannot tolerate the pain, let me know. I’ll adjust the intensity. The reason why
I’m giving you this treatment is to create a mild inflammation process to kickstart the healing again.
After the treatment, you will see a bit or redness and maybe some bruising over that area. That’s
normal it will go away. I’ve set to 1500 hits. Do you have any questions? Do you understand what I’m
saying? Can I proceed?

There is no time for the treatment, treatment may last 10 mins you won’t know, based on how fast
you give the 1500 hits. If you set the frequency to 1Hz, then it will take 1500secs. Once you find the
spot where the patient feels the pain, you don’t have to move it, but you can angle it slightly.

If the patient says its too much I cannot take it, you can wait awhile, or adjust the settings. You don’t
have to keep it at the same intensity and and the same frequency

Don’t cover the fan, the machine will suffocate

After the treatment as the patient how he feels?

The applicator has different sizes, more pointed applicator for smaller area more sharper pain.

Applicator you need to angle it slightly to try and get the shockwave delivered in a different
direction. You are looking for a soft spot. If you want to apply ESWT for your patient, before start
you should palpate where exactly is the patient feeling pain, and put a mark there.
If patient is voices out the spot that they are feeling the pain then that’s the spot I’ll leave apply the
ESWT at.

Ultrasound:

Safety procedure before you apply US:

Ask the patient what’s wrong, and check for contraindications. Examine the area (see if there is any
swelling, restriction on movement, broken skin) before US can be applied.

Informed consent : tell patient that you’re going to do US, + warning

Warning : what this US will do, How long is the treatment, what you should feel, what you should
not feel, Do you understand what I’m saying? Any questions? Can I proceed?

US you need to both skin sensation tests

I’m going to give you this treatment and as a precaution for some of the contraindication conditions
that you’re not supposed to receive this treatment, I’m just going to ask you a few
questions…

Place patient comfortably over the hole of the bed/plinth.

Poor connection, check the patient connection

FES: you want muscle contraction, first you will get some tingling sensation before muscle contracts

Tell patient what they should feel/expect: you should feel a muscle contraction because you’re
purposely setting it for muscle contraction. You should feel the contraction for 5
seconds. It will slowly come up for 5 secs because of the ramp up, then stay on for
another 5 secs, after which it will disappear which is rest time (15secs or 30 secs).
During the time which you feel the contraction, I need you to contract your muscle.
The cycle will repeat itself for 15mins or 20 mins (whatever treatment time you set).
If you feel it is too intense or too uncomfortable, then let me know I’ll change it for
you. Do you understand what I’m saying? Any questions? Can I proceed?

What you want patient to feel changes (this part of the warning you give changes)

After I’ve done the treatment, I’ll remove the electrodes and check for any redness on the patient’s
skin. If there is, assure the patient that it is normal and it will go away after awhile. (Since this is not
about pain, you don’t check pain score. You need to examine strength of the muscle). I’ll
check/reevulate the patient’s muscle strength using MMT. Although I may not see any changes
because the patient did so much exercise. Ask patient if they can contract

Muscle weakness in the in the vastus medialis muscle of quadriceps. Patient gone through operation
(acl reconstruction) and now has difficulty activating the muscle. Use TENS to get
muscle activation.

How?

Create a training for the patient

When the current comes, the patient should try and straighten the knee. (can be done sitting or
supine also). When the current is not there the patient relaxes.

I’ll put the electrodes on you, when you feel the current, straighten your knee.

60Hz vs 10Hz

Higher Hz/frequency, you will get more constant contraction of the muscle

Ramp up time = 5 secs

On time = e.g. 5 secs ( hold contraction for 5secs)

Off time = should be longer so that patient got more rest time

Always think about patient comfort so do on supine is better than sitting because of better back
support for patient.

Skin sensation test – make sure to test cover the area you’re going to treat