Electrical Muscle Stimulation
Electric stimulation can used on muscles that have a nerve supply (are innervated) to stimulate them to contract through application of current through an electrode placed on the skin over the muscle. This external signaled muscle contract can strengthen healthy muscle, prevent or reverse disuse atrophy, maintain or improve mobility, promote peripheral circulation and prevent fibrotic changes.
This type of pulsed galvanic stimulation has been used in the rehabilitation of many condition including acute low back pain to reduce muscle spasm, post operatively to prevent disuse atrophy and soft tissue edema (swelling) in the setting of pain, and to retrain muscle that are not firing correctly or at all. Electrical stimulation of individual muscles is a means of providing exercise to muscles that the patient is unable to or forgotten how to contract voluntary.
Use of electrical stimulation is usually limited to the initial stages of treatment, such as the first few weeks after injury or surgery so that patients may quickly progress to more active treatment, which includes a restoration of range of motion and strengthening. It does not replace exercise or other forms of active rehabilitation. It may often be combined with ice or heat to enhance its analgesic effects.
Electrical stimulation of muscles can be used for:
- For relaxation of muscle spasm
- Prevention or retardation of disuse muscle atrophy
- Increasing local circulation
- Muscle re-education
- Maintaining or increasing range of motion
- For relief of chronic pain, intractable pain, and/or acute, post-traumatic pain.
With correct dosing and methodologies, research has shown that electrical stimulation preferentially recruits type II muscle fibers and assists with neuromuscular re-education. This is important for deconditioned and post-operative patients who are unable to generate meaningful voluntary muscle contractions and exercise efforts. In our clinic, we often combine electrical stimulation of muscles with therapeutic exercise, especially in cases of incorrect/inefficient muscle recruitment patterns.
Transcutaneous Electrical Nerve Stimulation (TENS)
Transcutaneous Electrical Nerve Stimulation is a generic name for a method of nerve stimulation designed to control pain. TENS does this by overriding the painful signals that are sent to the brain with electrical impulses. There are now a variety of TENS units designed for specific modes of application. The different modes are identified by their parameter ranges of amplitude, frequency and pulse width. The units are small, battery powered and light weight weighing only a few ounces. Electrodes are placed on the skin near the area of pain and are attached to the TENS unit.
Transcutaneous electrical nerve stimulation (TENS) has been used to treat a variety of pain conditions. Success rates range greatly due to many factors including electrode placement, chronicity of the problem, and previous treatments. It is generally used in chronic pain conditions and not indicated in the initial management of acute low back pain. Documentation of greater than 50% reduction in pain with a treatment trial may help substantiate its true beneficial effects as opposed to a placebo response.
A physical therapist or physical therapy assistant instructs the patient on the positioning of the electrodes and the duration and frequency of the treatment and also sets the parameters for the amplitude, frequency and pulse width based on the patient's individual needs. The TENS unit is used at home by the patient for use as instructed as part of a comprehensive treatment program designed for the appropriate management of pain.
Ultrasound
Ultrasound is a name given to sound waves that are of such high frequency that they are not detectable by the human ear. The sound waves when applied to human tissue are absorbed by the body with the production of heat. The heat from Ultrasound penetrate heat into human tissues deeper that any other heat modality, 4-6 cm. The benefits of heating effect from ultrasound include promotion of muscle relaxation, increased local metabolism and reduction of pain by sedating nerve endings.
Ultrasound waves also have non-thermal benefits resulting from vibration of molecules. These effects include increases in the flexibility of connective tissues such as joint capsules, ligaments, tendons, adhesions, scars and cellular membrane permeability that accelerates healing.Therapeutic ultrasound is a safe and effective tool for treating a variety of conditions that a physical therapist commonly encounters.
Ultrasound is not indicated in acute inflammatory conditions where it may serve to exacerbate the inflammatory response and typically provides only short-term benefit when used in isolation. Pulsed and continuous modes allow for ultrasound to be used for both acute and chronic cases and ultrasound is most effective as part of an overall treatment plan, including therapeutic exercise and mobilization.
Some of the benefits of ultrasound:
- For pain reduction
- Relaxation of muscle spasm
- Treatment of contractures
- Improving local circulation to accelerate healing
- Increasing collagen extensibility,
- Treatment of tendonitis, arthritis, decreasing joint stiffness and bursitis
- Ultrasound can facilitate tissue healing and increase localized tissue temperature.
Iontophoresis
Iontophoresis is a means of delivering steroids through the skin. The steroid cream is applied to the skin and then an electrical current is applied to the medicated skin by way of an electrode that causes the medication to migrate under the skin. The steroids then produce an anti-inflammatory effect in the general area to relieve pain and inflammation. This modality is especially effective in relieving acute episodes of pain.
Assistive Devices
A variety of implements or equipment used to aid patients in performing tasks or movements. Assistive devices include crutches, canes, walkers, wheelchairs, power devices, long-handled reachers and static and dynamic splints. Therapists can help fit and instruct the patient in the use and care of the assistive device with the goal being optimal independence and safety.
Traction
Traction refers to the therapeutic use of manual or mechanical tension from a traction machine applied to the body through halters or straps to distract the spine. The goal is to decompress and create space in the joints of the spine between the vertebrae.
Indications for traction therapy include, but are not limited to, decreased sensation that temporarily improves with manual traction, increased muscle tone that is reduced with manual traction, extremity pain or tingling that is temporarily relieved with manual traction, spinal nerve root impediment due to bulging, herniated or protruding disc and muscle spasms that are causing nerve root impingement and general hypomobility of lumbar or cervical spine regions.
Prosthetic/Orthotic Training
A prosthesis is an artificial device, often mechanical used to replace a missing part of the body. This may be an artificial/prosthetic leg or arm that worn over an amputated limb.
Prosthetic training involves working with an amputee on overall conditioning as well as specific stretching and strengthening of the involved limb and training in the use and wearing of the prosthesis. Therapy also emphasizes care of the amputation site and performance of tasks of daily living with the prosthesis
An orthosis (as opposed to a prosthesis) is a device that supports weak or ineffective joints or muscles, such as a splint, brace, shoe insert or cast. Orthotic training concentrates on the increase of motion, function and use of a limb that requires an orthosis for support. Therapy also emphasizes balance and coordination of activities.
Heat and Cold Therapy
Heat and/or ice are easily available and are the most commonly used type of modality. Each type of therapy helps reduce muscle spasm and inflammation.
Some patients find more pain relief with heat therapy using heat packs and others with cold therapy such as ice massage. The two may also be alternated.
Superficial Heat
Superficial heat can produce heating effects at a depth limited to 1-2cm. Deeper tissues are generally better heated by ultrasound which is less susceptible to the thermal insulation of subcutaneous fat and the increased cutaneous blood flow which dissipates heat. Ultrasound penetrates up to 4-6 cm of tissue.
Superficial head has been found to be helpful in diminishing pain and decreasing local muscle spasm. Superficial heat, as applied via the hydrocolater pack, should be used as an adjunct to facilitate an active exercise program. It is most often used during the acute phases of treatment when the reduction of pain and inflammation are the primary goals. If beneficial, it can be incorporated into the education program and utilized on a home basis prior to the therapy program.
Cryotherapy
Ice packs or cryotherapy are generally more effective in terms of depth of penetration than other hot packs. Intramuscular temperatures can actually be reduced by 3-7 degrees C. This is helpful in reducing local metabolism, inflammation, and pain. The analgesic effects of ice result from a decreased nerve conduction velocity along pain fibers and a reduction of the muscle spindle activity responsible for mediating local muscle tone. It is usually most effective in the acute phase of treatment, though the patient can use it after physical therapy or the home exercise program to reduce pain and the inflammatory response.