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Hvps & Interferential Stimulation


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    • 1. HVPS & Interferential Stimulation Adapted from Therapeutic Modalities: Art & Science , Knight & Draper (2008) for KIN 195
    • 2. Competencies for Therapeutic Modalities TM-C2 Explain the principles of physics, including basic concepts associated with the electromagnetic and acoustic spectra (e.g., frequency, wavelength) associated with therapeutic modalities. TM-C3 Explain the terminology, principles, basic concepts, and properties of electric currents as they relate to therapeutic modalities. TM-C4 Describe contemporary pain-control theories.
    • 3. Competencies for Therapeutic Modalities, cont. TM-C6 Explain the body's physiological responses during and following the application of therapeutic modalities. TM-C7 Describe the electrophysics, physical properties, biophysics, patient preparation and modality set-up (parameters), indications, contraindications, and specific physiological effects associated with commonly used therapeutic modalities. TM-C8 Identify appropriate therapeutic modalities for the treatment and rehabilitation of injuries and illness.
    • 4. Law of DuBois Reymond:
      • The amplitude of the individual stimulus must be high enough so that depolarization of the membrane will occur.
      • The rate of change of voltage must be sufficiently rapid so that accommodation does not occur
      • The duration of the individual stimulus must be long enough so that the time course of the latent period (capacitance), action potential, and recovery can take place
    • 5. For all modalities…
      • Know the effects, indications, contraindications, & precautions
      • Verify the modality is set up correctly before treatment begins
      • Prepare the patient psychologically & physically for the treatment
      • Begin treatment conservatively and ask for patient feedback
      • At the end of treatment, clean up the modality and instruct the patient about next treatment and activity level until then
      • Maintain the machines appropriately
    • 6. Review: Requirements for Ion Migration: Chemical Effects
      • Must have continuous monophasic DC electron flow to cause ion migration.
      • Moving electrons against gradient
        • Like pushing a car uphill
        • When you pause, it rolls back down.
      • Why does a twin-pulse high-volt current not produce a chemical effect?
    • 7. Review: Pulse and Cycle Characteristics (cont.)
      • Pulse named by number of phases
        • Monophasic
          • One phase
          • Current flows in one direction only.
        • Biphasic
          • Two phases
          • Current flows in both directions.
        • Polyphasic
          • Many phases
    • 8. Review: Current Timing & Modulation
      • Pulse width (pulse duration)
        • Time required for each pulse to complete its cycle
        • Reported in microseconds or milliseconds
      • Short pulse duration: <150 µ sec
      • Long pulse duration: >200 µ sec
      • Interpulse interval
        • Time between successive pulses
    • 9. Commonly Used Wave Forms (p. 142, cont.)
      • Twin pulse wave form
        • Monophasic, pulsed, twin spiked
        • Common wave form of high-volt muscle simulators
        • Has been called high-volt galvanic and pulsed direct current
        • However, not direct or galvanic current
        • Result of misunderstanding physiology
    • 10. High Voltage Pulsed Current Stimulation for Wound Healing
      • Electrical stimulation for the purpose of repairing tissues includes management of open wounds and edema reduction.
      • Production of a twin-peak, monophasic, pulsed current driven by its characteristically high electromotive force or voltage
      • Positive or negative polarity
    • 11. HVPC Common Treatments
      • Versatile and can perform several functions:
        • Wound healing (only proven electrical modality proven to promote wound healing)
        • Pain modulation (acute & chronic)
        • Muscle reeducation and spasm reduction
        • Edema reduction (maybe)
    • 12. Characteristics of High-Volt Stimulator
      • Low volt stimulators generate <150 V
      • High volt stimulators generate >150 V
      • HVPC uses between 150 and 500 V.
      • Low average current
      • Twin peak monophasic waveform
        • Resembles a double spike with a fast rise followed by a fast decline
      • Short pulse widths (100 – 200 µ sec)
      • Pulse rates of 1 – 200 Hz
      • Generally HVPS uses lower current
    • 13. Review
      • What is HVPS stand for? Why isn’t it HVGS, according to Knight & Draper?
      • Describe the HVPS waveform.
      • Name the 4 common uses for HVPS.
      • Does HVPS utilize high voltage or high current to achieve outcomes?
      • What is the voltage cutoff between high and low voltage stimulators?
    • 14. HVPC: Uses & Techniques
      • Monophasic current used for
        • Wound management
        • Acute pain reduction
        • Reduction of edema
      • Bipolar Technique
        • Bipolar used for muscle contraction or chronic pain (Note: HVPS is not as effective as NMES for muscle contraction b/c of lower current in HVPS)
    • 15. HVPC: Advantages
      • 1. Less resistance to the current by the skin
      • 2. Short phase duration allows for moderately high-intensity muscle contraction with little discomfort
        • Other types of stimulators provide a stronger contraction
      • 3. Highly variable in its functions
      • 4. Can be used for
        • Wound healing
        • Pain modulation
          • a. Sensory level (acute pain)
          • b. Motor level (chronic pain)
        • Treating muscle weakness
        • Edema reduction
    • 16. HPVC: Disadvantages
      • Disadvantages
        • Cannot provide as strong of a contraction as NMES
        • Many aren’t portable.
        • Sometimes trial and error are needed to determine electrode polarity for wound healing.
        • Effects (muscle contraction) are not as strong as low-volt units.
    • 17. HPVC: Indications & Contraindications
      • Indications
        • Wound lesions (pressure sores, scarring from incisions)
        • Edema control and reduction
        • Residual or chronic muscle spasm (when low-volt unit unavailable)
        • Pain
      • Contraindications
        • Do not use on patient with pacemaker
        • Do not use over
          • Heart or brain
          • Lumbar and abdominal area of pregnant women
          • Potential malignancies
          • Anterior cervical area
    • 18. HPVC Precautions
      • Precautions
        • 1. Be cautious when using HVPC over an area with:
          • a. Impaired sensation
          • b. Extensive torn tissue (no use of bipolar)
          • c. Hemorrhagic area
        • 2. Patients with epilepsy should be monitored during treatment.
    • 19. Review
      • What are the monopolar and bipolar uses of HVPS?
      • Name the 4 advantages of HVPS?
      • Name the 4 disadvantages of HVPS?
      • What are the 4 indications for HVPS?
      • What are the 5 contraindications for HVPS?
      • What are the 4 precautions for HVPS?
    • 20. HVPC: Wound Management
      • How does HVPC stimulate wound repair?
        • Body possesses bioelectric currents in the vascular and interstitial tissues.
        • Blood vessel walls, insulating tissue matrix, interstitial fluid, and intravascular plasma are capable of conducting bioelectricity.
        • When tissues are damaged, an electrical potential is created between injured and noninjured tissues.
    • 21. HVPC: Wound Management (cont.)
      • Polarity may stimulate cellular activity when injured.
      • Stimulating d é bridement of injured tissues
      • Tissue regeneration and remodeling
      • May speed up healing by promoting the natural healing process
      • May develop a difference in potential between wound area and the surrounding healthy tissue
      • Injury potential typically becomes positive 24 – 48 hr after injury & negative 8 – 9 days after injury.
      • As the wound heals, the difference slowly returns to baseline.
        • Can be used to enhance the natural process of tissue recovery and healing
    • 22. HVPC: Edema Management
      • Curbing edema formation
        • HVPC does not use DC
        • Decreases the permeability of microvessels
        • Decreases the leaking of vessels, reducing the number of plasma proteins and amount of fluid that leave the vessels to enter the interstitial spaces
    • 23. HVPC: Edema Management (cont.)
      • Two protocols for curbing edema
      • Water immersion
          • -Negative polarity
          • -120 pps
          • -90% of visible motor threshold
          • -30 min treatments every 4 hr
          • -Apply ASAP postinjury or as long as edema is still forming
      • Resolution of edema once formed
        • -Can be employed in a muscle pumping action to get rid of edema
        • -Intensity increased until strong muscle contraction
        • -Setting of 1 – 10 pps for muscle contraction
    • 24. HVPC: Pain Modulation
      • Ineffective in reducing the pain of delayed-onset muscle soreness
      • Yet has been shown to help relieve pain caused by muscle spasm
    • 25. HVPC: Electrode Polarity
      • Negative polarity
        • Increases
          • Vascularity
          • Stimulation of fibroblastic growth
          • Collagen production
          • Epidermal cell migration
        • Inhibits bacterial growth
      • Positive polarity
        • Increases macrophages
        • Promotes epithelial growth
    • 26. HVPC: Electrode Polarity (cont.)
      • Most treatments begin with the negative polarity
        • Encourages blood clots to dissolve and increases the inflammatory by products
          • Necrotic tissues
      • Positive polarity encourages clot formation around the wound and granulation tissue.
    • 27. REVIEW: Phases of the Inflammatory Process
      • Phase I: Acute Phase ( 2 subphases)
        • Early (Acute): inflammatory response: lasts 2-4 days
        • Late (Sub-Acute): continue inflammatory phase which is usually complete in 2 weeks
      • Phase 2: Tissue Formation (Proliferation)
        • Tissue rebuilding approximately 2-3 weeks
        • This does not include chronic inflammation
      • Phase 3: Remodeling Phase
        • Adapt to original tissue
        • Continues for up to 1 year post injury
    • 28. REVIEW: Phase II, Stages of Regeneration
      • Stage starts with periphery/outside
      • Re-eptheliaization is proliferation of peripheral epithelial tissue which then migrates to the wound until the area is covered.
      • Capillarization (Capillary buds proliferate and connect forming new capillaries which gives the red, granular appearance to the scar (granular tissue)
    • 29. REVIEW: Chronic Inflammation
      • Complications
        • Granuloma: large mass of weaker scar tissue (usually due to large inflammation and activity without regard to healing time)
        • Retardation of muscle fiber: with excessive granuloma fibroblasts cannot reach damaged tissue
        • Adhesions/contractures in tissue
        • Keloid/hypotrophic scars
    • 30. Application Parameters: HVPC
      • Frequency of application
      • As often as three per day if separated by 3–4 hr
      • When using the monopolar function, active electrode over the injury and dispersive over a large & remote site
      • When using the bipolar function, place electrodes proximal & distal to the muscle belly
      • Length of application
      • 15 min if pulsed or patient is going to exercise post treatment
      • 15 to 30 min if surge mode is used or patient is not going to exercise post treatment (longer tires out the muscle)
    • 31. Review
      • How does HVPS stimulate wound repair (10 ways)?
      • What are the 2 ways HVPS manage edema? What are the 2 protocols?
      • What are the 5 things negative polarity in HVPS effects? What are the 2 things positive polarity in HVPS effects?
      • What are the common pad placements, duration and frequencies of treatment w.r.t. HVPS?
    • 32. Interferential Current
      • Interference or superimposition of two separate medium-frequency sinusoidal currents on one another
      • Symmetrical, sinusoidal, medium frequency (2000 – 5000 Hz) AC
      • Invented in 1950; used in United States by 1980s
      • Fifth most frequently used physical agent
    • 33. Most Commonly Used Wave Forms
        • DC: DC
        • IF: Polyphasic
        • HV: Twin pulse
        • LV : Biphasic and polyphasic burst (Russian)
        • TENS: Biphasic
    • 34. Commonly Used Wave Forms (p. 142, cont.)
      • Interferential wave form
        • Symmetrical, sinusoidal, high frequency (2000 – 5000 Hz) AC
        • Two channels, with different frequencies, used simultaneously
        • Two currents cause a tissue current amplitude modulation
    • 35. Commonly Used Wave Forms (p. 142, cont.)
      • Interferential wave form: current amplitude modulation
      Two identical currents Two opposite currents Two offset currents Usually accomplished with two different frequency currents
    • 36.
      • Basic principle
        • Decrease tissue impedance (resistance) so simulation is less painful
          • Impedance at 50Hz = ~3200 Ω
          • Impedance at 4000 Hz = ~40 Ω
          • Current passes more easily through skin
      • Advantages of vector pattern
        • Surface and deep stimulation
        • Targeted tissues for added benefit
        • Treatment of easily localized pain
        • Treatment of large areas
        • Treatment of poorly defined pain
      What Is IFC Therapy?
    • 37. How Does IFC work?
      • Example: One channel runs at 5000 Hz another at 5100 Hz
        • Use a dynamic vector (or scan for poorly defined pain)
        • Use target for easily localized pain
        • Treats most of the area bracketed by the electrodes (scan or dynamic vector)
    • 38. Is IFC Therapy Effective?
      • Those who have had success
        • Correctly position vector
        • Use appropriate size and positioning of electrodes
        • Use appropriate stimulation parameters
        • Persevere, if pain relief is not immediately obtained
    • 39. Review
      • What is the basic principle of IFC?
      • What’s the advantage of the vector pattern?
      • What is the waveform of IFC?
      • Why does IFC use 2 currents?
      • What are 4 ways to increase the chances of effectiveness using IFC?
    • 40. IFC advantages & disadvantages
      • Advantages
        • 1. More comfortable than a TENS unit
          • a. Medium-frequency currents meet with less skin resistance than low frequency currents; TENS uses low frequency currents
        • 2. Stimulates tissues deeper than a
        • TENS unit
        • 3. Larger coverage area than TENS
      • Disadvantages
        • 1. Eliminates pain; doesn't deal with
        • cause of the pain
        • 2. May mask more serious problems
        • 3. Few portable units available
        • 4. Sometimes becomes a panacea
    • 41. IFC: Indications & Contraindications
      • Indications
        • 1. Acute pain
        • 2. Chronic pain
        • 3. Muscle spasm
        • 4. Pain that covers a large area
      • Contraindications
        • 1. Do not use on a person who has:
          • a. Implanted pacemaker
          • b. History of heart disease
        • 2. Do not treat transthoracic area
        • 3. Discontinue if skin irritation develops
    • 42. IFC: Precautions
      • Precautions
        • 1. Be cautious when using IFC over:
          • a. Impaired sensation
          • b. Skin lesions (cuts, abrasions, new skin, recent scar tissue, etc.)
        • 2. Use caution when using IFC while driving or operating heavy machinery.
        • 3. A temporary decrease in pain does not mean the cause of the pain has gone.
    • 43. Application Parameters: IFC
        • Adjust pulse rate settings for specific injury
        • a. For acute pain
            • i. Use a high pulse rate of 80 – 200 pps
            • ii. Pain relief is almost immediate
            • iii. Lasts only a few minutes to 1 hr
          • b. For chronic pain
            • i. Use a low pulse rate of 1 – 5 pps
            • ii. Pain relief may take ½ hr
            • iii. May last 6 – 7 hr
        • Target or vector
          • a. Pain that is easily identifiable and pinpointed
            • i. Use target or vector buttons to move spot
            • where current intersects to area directly
            • over pain
          • b. Pain that is hard to pinpoint
            • i. Use dynamic vector
    • 44. Application Parameters: IFC (cont.)
      • --Length of application: 20 – 30 min
      • --Frequency of application: Once or twice daily, as needed for pain
      • --Duration of therapy: Use until IFC is no longer effective.
    • 45. Review
      • What are the 3 advantages of IFC?
      • What are the 4 disadvantages of IFC?
      • What are the 4 indications for IFC?
      • What are the 4 contraindications for IFC?
      • What are the 4 precautions for IFC?
      • What’s the pps range to treat acute pain? Chronic pain?
      • When should vector or target modes be used during IFC treatments?
      • What are the length, frequency, and duration of IFC treatments?