Sample Outline: Electrodiagnosis

Electrodiagnosis

The detection of electrical reaction of muscles and nerves for diagnosis, prognosis and therapy by the use of electrotherapeutic current and electromyography. It is the study of electrical activity in motor units when stimulated by electrical pulses.

Uses:

1. Presence of normal and abnormal electrical excitability

2. Limits of pathology

3. Involvement of motor and sensory components

4. Presence of demyelination and axonopathy

5. Know the extent of pathological changes

Physiological Basis of Electrodiagnosis

1. Stimulation of Nerve Fibers

-Electrical potential of nerve is 90 mv

-demonstrates accommodation

2. Stimulation of Muscle fibers

- potential difference of 70 mv

3. Refractory Period- amount of time takes for an excitable membrane to be ready for a second stimulus once it returns to its resting state following an excitation

- absolute

-relative

4. Accomodation – the ability of the tissue to adapt itself to slowly increasing intensity

- Law of Dubois of Reymond

- in denervated muscle , it has lost power of accommodation except for long duration and slow rise peak intensities will be able to produce a brisk contraction

5. Action Potential

-impulse

-ability of a nerve and muscle membrane to develop transient changes in potential which is transmitted from one point to another

6. Reaction of Degeneration – the failure of the muscle to contract when stimulate by a tetanizing current

-Partial Reactioon of Degeneration

-Full/Complete Reaction of Degeneration

-Absolute Reaction of Degeneration

7. Polarity Reversal

Cathode is more effective in normal nerve, partial and complete denervation

Anode is effective in degeneration with atrophy

**sometimes in complete or partial denervation, the reverse may occur. Try both

Contraindications

1. Pacemakers/ patient depending on cardiac device

2. Over the carotid sinus

3. Abdominal area during pregnancy

Sites of Involvement

1. UMNL

2. LMNL

3. Neuromuscular Transmission Disorder

4. Myopathies

5. Functional Disorders

Clinical Applications

*Anterior Horn Cells

Poliomyelitis

Progressive Muscular Atrophy

ALS

Syringomyelia

*Nerve Root

Prolapsed

IV disc traction injuyry

Trauma

*Nerve Axon

Neuritis

GBS

*Myoneural Junction

MG

*Muscle Fibers

Myopathy

Dystrophy

*Plexus

Traction Injury

Wounds

Waveforms used in Electrodiagnosis

1. Rectangular

-Rheobase

-Chronaxie

-Nerve Excitability Test

-SDC

2. Rectangular and Triangular

- Galvanic/Faradic

Methods of Electrodiagnosis

1. Rheobase and Chronaxie Test

*Rheobase- measured using the cathode on the motor point of the nerve or bipolar technique

- it is the intensity of current needed to produce a minimal perceptible and palpable contraction

N ormal Value = 2-18 mA or 5-35 V

*Chronaxie- time necessary to induce minimal visible contractions with the stimulus twice the rheobase

Normal Values = < 1 ms

2. Pulse Ratio

- Ratio of the intensity of the current needed to produce a muscle contraction with 1 ms duration to that required if the duration of the pulse is 100 ms.

- A crude test:

Innervated- little or no difference but always lesser than 2.2:1

Denervated- > 2.5:1

Complete Degeneration- no response to 1

3. Nerve Excitability Test

- An electrical test which uses a short duration pulsed low frequency current to determine the state of excitability and conduction of a nerve trunk

- Performed 1 -2 days after onset of paralysis and repeated periodically

- Stimulating Points of Nerve Trunk

a. Facial Nerve- 3 branches are anterior to the mastoid

b. Erb’s points- lower inner angle of supraclavicular fossa

c. Ulnar nerve- upper point- above the medial epi of the elbow

Lower point- just above the wrist near the ulnar border

d. Radial Nerve- halfway down the arm posteriorly

e. Tibial Nerve- slightly above the center of the popliteal crease

f. Common peroneal nerve- medial to biceps tendon at the poplietal crease

g. Deep peroneal nerve- just behind of fibula

h. Superficial peroneal nerve- one cm below the deep peroneal nerve

4. Strength Duration Curve

- Intensity/time curve, intensity/duration curve

- A curve obtained by joining points that graphically represent the threshold values along the ordinate for various durations of stimulus displayed along abscissa

5. Reaction of Degeneration Test

-a gross screening test to differentiate a muscle with (N) peripheral innervations from a muscle with peripheral denervation

- done 10 days after the onset of the problem

-aka Galvanic Faradic Test

6. Nerve Conduction Test

-asses the time and quality of the conduction of neural impulses In peripheral motor and sensory nerves

Reference: Electrophysical Agent by Wadsworth

Techniques of Application: Fluidotherapy

Fluidotherapy

Fluidotherapy is a dry heat agent that transfers heat through convection. Warm air is circulated through a container with extremely solid particle. The solid particle is suspended by circulating air thus producing an effect similar to circulating warm liquid. The fluidotherapy unit comes in different sizes with four openings for the insertion of limb. The upper opening is used for distal upper extremities and the lower opening for lower distal extremities. Some paraffin wax bath with larger units can accommodate the lower back and thigh areas.

Duration: 20 mins

Techniques of Application

1. Get the patient’s Vital Signs
2. Let the patient washed the area to be treated (usually hand and foot) and remove all the jewelries.
3. Position the patient with the part to be treated relaxed and comfortable
4. Inspect the area to be treated for abrasions, cuts, wounds, scars, edema and other circulatory dysfunction.
5. Test patient’s sensation as to hot and cold
6. Give the rationale to the patient as to the intensity, duration and the purpose of the treatment
7. Insert the part into the sleeve and close it snugly around the more proximal portion of the limb
8. Instruct the patient not to come out once the blower is turned on
9. Set the thermostat usually 38.8 to 47.8 deg C (102 to 118 def F)
10. Set the timer for 15 mins
11. Instruct the patient to exercise the extremities while inside the unit if indicated to the treatment. PT can also used the other openings to stretch and help the patient exercise.

Post Treatment Procedure

1. When treatment is finished, loosen the sleeve

2. Help the patient to remove all particles before removing the limb in the unit

3. Inspect the part

4. Get Vital Signs or proceed to other treatment if necessary

References:

Thermal Agents in Rehabilitation by Michlovitz

Physical Agents by Hecox

Electrophysical Agent in Physiotherapy by Wadsworth

Techniques of Application: Paraffin Wax Bath

Paraffin Wax Bath

Paraffin wax bath is one the most convenient, accessible and reasonably efficient in heating distal extremities such as fingers and feet. It is a mixture of paraffin and mineral oil in ratio of 6:1 or 7:1.

The wax melting point is around 52 to 54 degree C.

Paraffin wax bath has 3 properties:

1. Low Specific Heat – this is due to capability of mineral oil to lower paraffin melting point

- Patient can tolerate the heat of the paraffin than the other heating modalities.

2. Low Thermal Conductivity- it gives off heat slowly
3. Self Insulating- capability of a wax to form a layer that creates a thin layer of air next to the skin which acts as an insulator

*Paraffin Wax Bath can increase skin temp up to 12 to 13 deg C in first 2 mins.

*At the end of the treatment , it can increase 5 deg C in fascia and 2-3 deg C in superficial muscles.

Duration: 15-20 mins

Techniques of Application

1. Get patient’s vital sign
2. Check the paraffin temp. It should be around 40 to 44 deg C on the thermometer. You can also test by dipping your fingers directly to the wax. Show it to the patient as a demonstration.
3. Let the patient washed the area to be treated (usually hand and foot) and remove all the jewelries,
4. Position the patient with the part to be treated relaxed and comfortable
5. Inspect the area to be treated for abrasions, cuts, wounds, scars, edema and other circulatory dysfunction.
6. Test patient’s sensation as to hot and cold.
7. Give the rationale to the patient as to the intensity, duration and the purpose of the treatment
8. Position the patient and instruct him to dip the part in and out of the paraffin so that a thick coat of paraffin congeals on the skin. (usually 10 dips)
9. Wrap the part in a layer of greaseproof of paper and towels to retain the heat.
10. Set a timer. Treatment time of 15-20 mins

Post Treatment Procedure

1. When the treatment completed, remove the towel carefully
2. Remove the paraffin glove by loosening the top going down
3. Inspect and dry the area treated
4. After removal, the paraffin glove is deposited to a special container and will be placed back and melted in the paraffin bath at the end of the day.

Common Techniques in the Application of Paraffin Wax Bath

1. Dip- Immersion Technique – patient dip in the paraffin bath ten times and will be immersed for 15 mins
2. Glove Technique – patients dips in the paraffin bath ten times and will be covered by paper and towel for 15 mins
3. Brush Technique- commonly used for children, with fingers separated, PT dips and brushes the patient’s finger until a layer of paraffin is formed. Wrapped the area for 20 mins.

References:

Thermal Agents in Rehabilitation by Michlovitz

Electrophysical Agents in Physiotherapy by Wadsworth

Physical Agents by Hecox

Techniques of Application: Hot Moist Pack

Hot Moist Pack (HMP)

HMP provides superficial moist heat. It is made up of bentonite and silica gel. The gel has a property to absorb more water than its own which give off moist heat for 30 to 40 mins. The HMP is heated in a hydrocollator tank with a temperature of 76 to 80 degree Celsius (165 to 175 degree F)

The packs are in different sizes and shapes. Common sizes are the standard, low back and cervical packs. They are usually covered by Turkish towel, terry cloth or a bathroom towel with 4-6 layers (Wadsworth)6-8 layers (Michlovitz) 6-12 layers (Hecox).

Duration of Treatment : 20 – 30 mins

Techniques of Application:

1. Get the patient’s Vital Signs

2. Position the patient with the part to be treated relaxed and comfortable

3. Inspect the area to be treated for abrasions, cuts, wounds, scars, edema and other circulatory dysfunction.

4. Test patient’s sensation as to hot and cold

5. Do not expose the patient unnecessarily

6. Give the rationale to the patient as to the intensity, duration and the purpose of the treatment

7. Inform the patient to alert you if any pain, discomfort or burning sensation is felt

8. Remove the hot pack from the tank with tongs

9. Place the hot pack in a terry cloth or towel. Ensure that there will be 6-8 layers from the HMP and the patient’s skin.

10. Place the hot pack on the appropriate body area and secure it firmly to prevent slipping.

11. Tell the patient not to fall asleep

12. Check the patient every 5 mins to ensure that no extremely hot red areas or burns have developed.

Post Treatment Procedures:

1. Dry and inspect patient’s skin
2. Put the pack back in the tank
3. Hang the towels and covers to dry
4. Change patient’s towel if wet and if necessary
5. Get the patient’s Vital signs before leaving

References:

Thermal Agens in Rehabilitation by Michlovits

Electrophysical Agents in Physiotherapy by Wadsworth

Physical Agents by Hecox

Sample Outline: Superficial Heating Modality

Superficial Heating Modalities

Conductive Heating- transfer of heat between two objects in contact

Example: Hot Moist Pack, Paraffin Wax Bath

Convective Heating- transfer of heat by means of convection currents, which arise due to temperature and density differences in various parts of a fluid

Example: Fluidotherapy

Radiant Heating- emitted from a substance with a temperature greater than absolute zero, it can flow without any medium

Example: Infrared Lamp

~Biophysical Effects of Heat

The skin tolerance to heat is 44 degree Celsius.

*42 degree Celsius for 2 hours can cause burn

*44 degree Celsius for more than 30 mins can cause burn

* greater than 45 degree Celsius 5 to 10 mins cause burn

*** the safest temp is 44 degree Celsius fro 20 -30 mins

1. Metabolic Reactions- governed by Vant Hoff’s Law

- Energy expenditure will increase in increasing temperature

- 2 possible reactions

a. Increase in phagocytosis which hasten the healing process and repair of damaged tissue

b. Arteriolar dilatation

2. Vascular Effects

- Decrease viscosity of blood

- Due to Vasodilation

Effects of Vasodilation

a. Increase in nutrient s and leukocytes that enhances tissue healing

b. Increase in the rate of clearing metabolites which decrease pain and muscle spasm

c. Increase the amount of cooler blood arriving at the area and warmer blood being carried away which helps prevent tissue damage

*Relflex Heating- technique which the application of heat in one area of the body lead to an increase in cutaneous circulation and other reactions in another body.

- usually used for patient with Diabetes Milletus and Peripheral Vascular Disease

- Example:

heating the leg or arm opposite to the one heated

ipsilateral extremity upper extremity when the lower extremity is heated

lower extremity when the lower back or abdomen is heated

3. Neuromuscular Effects

- Provide analgesia

- Assist in the resolution of muscle-guarding spasms through:

*Elevate pain threshold

*Alter nerve conduction velocity

*Change muscle spindle firing rate

- Alter Strength and Endurance – decrease in strength and endurance during or after exposure to heat

4. Connective Tissue Effects

- With combination of stretching, heat provides elongation of connective tissue

Indication of Heating Modalities

1. Pain and Muscle Spasm

2. Sub Acute to Chronic Edema

3. Sub Acute to Chronic Inflammation

4. Adhesions and Scars with combination of mobilization and stretching

Contraindication of Heating Modalities

1. Impaired skin sensation

2. Dermatological conditions such as eczema and dermatitis

3. Circulatory dysfunction such as varicose veins and DVT

4. Patients taking analgesic Drugs

5. Acute infections and open wounds

6. Cancer and Tuberculosis

7. Lack of comprehension

8. Deep x-ray therapy within 3 months

9. Liniments

ReReferences:

TThermal Agents in Rehabilitation by Wolf

Thermal Agents in Rehabilitation by Susan Michlovitz

Electrophysical Agents in Physiotherapy by Wadsworth

Physical Agents by Bernadette Hecox

Sample Outline: Integumentary

Skin is the largest organ of the body

3 Functions of the Skin:

1. Protection – protect the body against infection by acting as a barrier

2. Sensation- serve as interface between outside environment and afferent nervous system

3. Regulation- regulates body temperature and fluid balance in conjunction with circulatory system

Layers of the skin

1. Epidermis

5 Layers:

Stratum Corneum- horny layer aka Stratum Disjunctivum

Stratum Lucidum – where you can find the elieden, clear layer

Stratum Granulosum – where you can find keratin

Stratum Spinosum

Stratum Basale aka Stratum Germanitvum where mitosis takes place

*Stratum Malphigi is the combination of stratum spinosum and basale

2. Dermis aka Corium

- Thicker in the hand and soles of the foot

2 Layers:

Papillary Layer- uppermost layer, vascular layer

Reticular layer- dry portion, more numerous in the regions of hair follicles, sebaceous and sweat glands

Accessory Organs

1. Hair follicles- keratinous filament from the matrix cells of follicular invaginations

2. Sweat Glands- Eccrine- found all over the body and the most numerous

Apocrine- found in axilla, eyelids, areola, external genitalia

3. Sebaceous Gland- found in hair and scalp, it produces sebum

Sensory Receptors of the Skin:

Mechanoreceptors: response to physical stimuli that causes mechanical displacement

Thermoreceptors: heat and cold receptors

Nociceptors: noxious stimuli

Electromagnetic receptors: rods and cons of the eye

Specific Skin Receptors:

Free nerve endings- detect touch and pressure

Merkel’s Disk- detects sustained touch and pressure

Meissner’s Corpuscles- change in texture

Pacinian Corpuscles- detects vibration and proprioception

Ruffini Endings- warm receptors

Krause end bulb- cold receptors

Sample Outline: Electromagnetic Spectrum

All substances with temperature above absolute zero emits radiant energy. (-273 degree Celsius.

Two theories of Energy transmission

1. Quantum theory – photon is produced by electronic or molecular motion of high velocity or by the kinetic energy released from the collision of molecule

2. Electromagnetic wave theory- energy is transmitted by oscillation in the form of electromagnetic wave

“the shorter the wavelength, the higher the frequency”

“the higher the frequency, the higher the energy content”

*wavelength – is the distance from the peak of one wave to the identical peak of the next wave

*frequency-is the number of oscillations or cycles per second

Electromagnetic Spectrum- representation of various waves energies arranged in order of their wavelength, frequency or both ( 0.0001 nm to .5 x 10 15 nm)

Radiant energy can be affected by the medium:

1. Refection- the angle of incident ray is equal to the angle of reflected ray

2. Refraction- the bending of waves when it enters a medium where it’s speed is different

3. Absorption- electromagnetic energy is transformed to other forms of energy such as heat

4. Penetration- measure how deep an electromagnetic energy can penetrate a tissue

Law of Optics

1. Law of Grotthus Draper: waves of different wavelengths produce different effects, and the extent of the effect will be determined by the amount of energy absorbed by the tissue

2. Law of Inverse Square: intensity of the wave is inversely proportional from the square of the distance from the source

3. Lambert’s Cosine Law- maximum absorption of energy occurs when the source is at the right angle to the absorbing surface

4. Bunsen Roscoe Law of Reciprocity: intensity and duration of the dose of radiant energy is inversely proportional

Eneargy= intensity X time

5. Wien’s Law- wavelength is inversely proportional to the absolute temperature

References: Thermal Agents in Rehabilatation by Hecox

Electrophysical Agents in Physiotherapy by Wadsworth

Thermal Agents in Rehabilitation by Wolf

Sample Case: Peripheral Nerve Injury

Px comes to you with a c/o weakness of (L) elbow flexors after holding the bag while doing her shopping. She also c/o numbness and paresthesia on the (L) lateral elbow that prompted her to see a Physiatrist.

The following also noted:

1. min weakness of (L) wrist flexors

2. (L) thumb numbness and paresthesia

3. (N) MMT of elbow extensors and wrist extensors

4. (N) ROM of all four extremities

5. inability to carry bags on the (L)

Give the following

1. MMT of any affected muscle above

2. Special Test to confirm px’s symptoms

3. DTR

Give the following Mx:

1. One electrotherapeutic agent

2. Four PT exercises

3. Two HI

Sample Case: Spinal Cord Injury

A T12-L1 Incomplete SCI patient is referred to your facility. Upon assessment, you noted the following manifestations:

1. Paralysis of (B) LE

2. Grade 5 muscle grade of (B) UE

3. Good Trunk Control

4. Good Sitting Balance/Tolerance

5. Can ambulate with the use KAFO and axillary crutches

6. Areflexia of (B) LE

7. Atonia of (B) LE

Perform:

1. Perform Sensory Testing of L2 (Write on your paper the procedure and the possible MMT grade)

2. Perform Special Test (Write the SPT with the procedure and response)

Perform:

1. w/c to bed transfer

2. floor to w/c transfer

3. Teach patient to go up and down the stairs

Sample Case: Cerebro Vascular Accident

A 58 yr old male patient with (L) MCA stroke 2 months status post has been admitted to your facility. Upon assessment, you noticed that the patient is already in GRADE 3 of Brunstromm Stage with the following manifestations:

1. Weak Ankle Dorsiflexor (R)

2. Trunk Control

3. Fair Standing Balance Tolerance

4. Can ambulate with the use of walker with moderate assist on the pelvis and shoulder

5. Grade 2 Spasticity on (R) UE and LE

6. Hyperreflexia on all tested parts

7. Slouched posture

With these manifestation, give the following:

1. Cranial Nerve Testing “direct and consensual reflex” (write on your paper the procedure and the response)

2. Sensory Testing “deep sensation”(write on your paper the procedure and the response)

Give (1) management in the following manifestations:

1. Exercise for posture (given the posture of the patient, PNF)

2. Exercise for ambulation(while the patient is ambulating)

Electromodality for grade 2 spasticity of (R) elbow flexor

Sample Test: Therapeutic Exercises

I. Enumeration

1-3. Indications of Aquatic Exercises

4-7. Precautions of Aquatic Exercises

8-10. Contra indications of Aquatic Exercises

II. Matching Type

1. Upward force that works opposite to gravity A. Buoyancy

2. Act as a membrane under tension B. Hydrostatic pressure

3. Pressure exerted in immersed object C. Thermodynamics

4. Movement where molecules move parallel to each other D. Laminar Flow

5. Physical properties and characteristics of fluid in motion E. Turbulent flow

6. Friction occurring between molecules of liquid F. Drag

7. Amount of heat required to elevate the temp of 1gm G. surface tension

of substance by 1 deg C H. NOTA

8. Cumulutative effects of turbulence and fluid viscosity

9. Reduces swelling and assists venous return

10. Most important properties of water in Aquatic Exercises

III. Modified True or False. Write True if the statement is Correct. If False, change the underlined word to make it True.

1. Manubrium is the center of buoyancy when immersed in water.

2. 33% of weight bearing is produce in C7 level.

3. Limits of stability is the sway boundaries in which an individual can maintain equilibrium without changing Base of Support.

4. Motor Strategies are balance control which part of Musculoskelatal System.

5. The systems of balance are visual, somatosensory and vestibular.

6. The main components of derived position are lying, sitting,kneeling,standing and hanging.

7. The best position to strengthen your gluteals is hook lying.

8. Mediolateral perturbations are utilized by Hip Strategy.

9. Synovitis is an inflammation of your synovial sheath.

10. The sub acute phase lasts for 7-21 days from the onset of injury.

IV. Identification

1. How many degree of elbow flexion is needed in measuring your cane?

2. The most stable assistive device is ______.

3. Best crutch to use if the patient has fracture of your radio-ulnar complex.

4. C5-C6 SCI patient will utilize this kind of crutch

5. Type of walker that promote trunk control

6. The most stable gait is _____.

7. An orthotic device use for househould and community ambulation

8. -10. Removable parts of Wheelchair