The principal mark of genius is not perfection but originality, the opening of new frontiers.

Arthur Koestler

Everyone should carefully observe which way his heart draws him, and then choose that way with all his strength. Hasidic saying

Sr. Marites O. Galvez BSPT - III

TABLE OF CONTENTS Title Pages

MICROWAVE DIATHERMY
History of Microwave Diathermy................................................ Diathermy

1 Nature of Microwave

1 1

Definition of Microwave Diathermy. Biophysics.. Effects.. Effects......................... Dosage Application . 4 4 5 6 6 6 6 3 2 Therapeutic

2 Physiological

3 Principle of

3 Indications

Contraindications Precautions Advantages... Disadvantages Treatment Duration Physical Behavior

Tissue Composition and Microwave Absorption.. Dangers of Microwaves. Morphological Effect. Picture of Microwave Diathermy. 7-8 9 10

WHIRLPOOL BATH History.

Definition .. General Description. 13 14

11 - 12

Two General Types............................................................. Precaution of Whirlpool. Use of Whirlpool Contraindications.

Temperatures Used Durations... 16 16

14

15 15 15
16

Most Contaminated Sites

Common Antibacterial Agents Disinfectant Used. Picture of Whirlpool Bath. 18

16 - 17

SITZ BATH
Definition History. Therapeutic Effects.. How to Take a Sitz Bath. Description 21 - 23 24 19 19 20 20

Picture of Sitz Bath

CONTRAST BATH
Definition. 25 25 25 26 26 27

Therapeutic Effects. ................ Technique of Application.. Methods of Application Mode of Transmission.. General Description..

Treatment Temperatures Treatment Duration. Treatment Procedure.. Indications.. Contraindications Precautions Picture of Contrast Bath. 28 27

27 27 27

28

29

PHONOPHORESIS
Definition.. 30 30 30

Common Use of Phonophoresis. Penetration of Phonophoretically Driven Drugs Drugs Used in Phonophoresis... Application.. Contraindications Picture of Phonophoresis. 33 34

31 - 32

35

TRANSCUTANEOUS ELECTRICAL NERVE STIMULATOR

Definition History. 36 36

Indications.. 36 Contraindications. 37

Methods of Application 37 Precautions 38

Advantages... 38 TENS Eletrode Placement 38 Physiologic Effects... 39 Picture of TENS.. 40

JOBST INTERMITTENT MACHINE

Definition. Effects of Jobst.. Compression... Two Parameters Pressure Applied... Duration of Treatment... Contraindications Picture of Jobst Intermittent. 42 43 41 41 41 41 41 42

INFRARED RADIATION
Definition 44 44 44

Physical Characteristic of Infrared Radiation.. Physical Behavior of Infrared Radiation.. Physiological Effects. Indications... Precautions. Contraindications.. Application Advantages 45 45 45 46 46 46

Disadvantages.

47 47 48

Things to Remember during IRR Application... Picture of Infrared Radiation..

ELECTROMYOGRAPHY
Definition History.. Procedure 49 49 50

What can EMG DIAGNOSE? ...................................................................................... 50 Normal Values... 51 Abnormal Values.. 51 Risks 52 Special Consideration 52 Picture of Electromyography.. 53

BIOFEEDBACK
Definition... 54 History. 55 General Principle.... 55 Physiologic Feedback. 55 Biofeedback in Rehabilitation 56 Relevance... 58 Picture of Biofeedback.. 59

MICROWAVE DIATHERMY
History
Microwave wave diathermy, although deeper than superficial (surface) heating, is not as deep as capacitive (shortwave or ultrasonic heating. In addition, microwaves produce some none thermal effects. In order to address concerns regarding hazardous exposure to

electromagnetic radiation, exposure standards have been developed by international and national authorities including the Canadian Department of Health and Welfare (1983), Australian National Health and Medical research Council (1985) (reproduced in Delpizzo and Joiner, 1987), National Radiation Protection Board (1989), De Domenico et al. (1990), and Australian standards Association (1992).

Nature of Microwave
The group of electromagnetic radiations known as microwaves occupy that part of the electromagnetic spectrum extending from wavelength 1m (frequency 300MHz) 1mm (300GHz). The operating specification for apparatus in Australia, the United Kingdom and Europe is 122.5mm (2450MHz), whilst physiotherapeutic microwaves in North America also operate at 327mm (915MHz) and 690mm (433.9MHz).

Definition

The term diathermy is refers to the therapeutic heating of tissues using electromagnetic radiation. Microwave diathermy means the application of electromagnetic radiation at microwave frequencies to cause deep tissue heating. Irradiation of tissues with radiation in the shorter wireless parts of the spectrum (Herzian rays) example the wave length infrared and shortwave diathermy. The general frequency of microwave is between 300 to 3000 MHz with wave length of 1m to 1mm. Frequently used frequency and wavelength are Frequency 2450 MHz 915 MHz 433.92 MHz Wavelength 12.25cm 32.7cm 69cm

Biophysics
Microwave does not penetrate tissue as deeply as shortwave diathermy and ultrasound. In addition, penetration decreases as frequency increases, and deeper heating occurs at 434 MHz than at 915 MHz or 2, 450 MHz. Leakage and focusing become more difficult problems with longer wavelengths. Microwave radiation is observed selectively by water and should preferentially heat muscle. However, fat temperatures may increase by 10C to 12C, whereas 3- 4 cm deep muscles will be heated only 3C to 4C.

Physiological Effects
The configuration of a pattern is determined and controlled by the distance that is placed from the patient and the shape of the reflector.

 The power output of the microwave unit is adjusted in accordance with the size and shape the body part treated. The smaller heat output of a microwave unit warms tissues in a much more local area. Most of the effects of microwaves radiation are due heating of tissues by conversion Consequence of heating due to Ionic movement Dipole Rotation Molecular Distortion Strongly absorbed by tissue of high water content

Therapeutic Effects
Relief of pain: by microwave diathermy is useful in the treatment of traumatic and rheumatic conditions affecting superficial joints. Reduce muscle spasm: may be reduced directly by microwave diathermy or may be reduced by relieving pain. Inflammation: increase in the blood supply will increase venous return from the inflamed area and aids the reabsorption of edema exudates. Delayed healing: to promote healing of open skin by increase cutaneous circulation. Infection: MWD can control the chronic infection by increasing the circulation. Fibrosis: heat increases the extensibility of fibrous tissues such as tendons, joint capsules and scars.

Dosage
20 min for vascular adjustment If significant heating required 30 min would be reasonable Intensity: the patient should feel mild and comfortable warmth.

 Frequency: daily or alternating day.

Principles of Application
Preparation of patient Preparation of apparatus Preparation of parts to be treated Setting up: Emitter should be positioned so that radiations strikes the surface at right angles Instructions and warning Application Termination

Indications
Musculoskeletal disorder Sprain-strain-muscle and tendon tear generative - joint disease - joint stiffness in superficial- capsular lesions Superficial in inflammatory or infective conditions Tenosynovitis bursitis synovitis infectected surgical incisions carbuncles abscess

Contraindications
Over malignant tissues Over ischemic tissues Over wet dressings and adhesive tapes Metal implants Pacemaker Over growing bones Male gonads: repeated irradiation can cause sterility Hemorrhage

Tuberculosis joints Impaired thermal sensation Unreliable patients The eyes: cause cataract Recent radiotherapy Hypersensitivity to heat Acute infection or inflammation Analgesic therapy: the thermal sensation diminished Venous thrombosis or phlebitis Pregnancy: heat applied to pelvis or hip in pregnancy may cause hemorrhage or miscarriage Menstruation Acute dermatological conditions Severe cardiac conditions Blood pressure abnormalities

Microwave Apparatus
The core of microwave apparatus, a multi-cavity magnetron valve, transmits microwave energy to one of a of variety different- sized circular or rectangular directors (antennae) via a shielded coaxial cable. In turn, the director radiates microwaves to the surface of the region to be treated in the same manner as a simple bar radiator.

Precautions
If vigorous heating effects are desired, the applicator must be brought close to the surface of the skin. The applicator should not be brought into the contact with the skin. Avoid sweat droplets forming on the skin that can be selectively heated.

During treatment near the head, the eyes should be shielded with special goggles. Watches must be kept away from the high frequency field. Hearing aids must be placed at least four feet from the treatment area. The director should be placed from 1-7 inches from the patient depending on the type that is used.

Advantages
Pain is relieved Healing of infection is faster Aids in relaxation

Disadvantages
Burns Injuries to eyes

Treatment Duration
Treatment duration exceeding 20 minutes is inadvisable.

Physical Behavior
On reaching the surface of the body (or other material) the initially radiated microwaves may be absorbed, transmitted, refracted or reflected according to the optical laws of radiation. These behaviors determine the distribution of the energy within the body. The propagation characteristics of microwaves are first determined by the wavelength and frequency of the energy. Whilst the penetration of microwaves is inversely proportional to their wavelength, this is not a simple (linear)

relationship because other factors such as tissue composition contribute to the final pattern of absorption. Muscle contains more dipole molecules than the

Tissue Composition and Microwave Absorption

Microwave energy is predisposed to penetrate tissues with low electrical conductivity and be absorbed in tissues with high conductivity. In essence, high electrical conductivity equates with high fluid content typically blood vessels, muscle, moist skin, internal organs and eyes. Microwaves of 122.5mm (2450 MHz) heat the skin at least to the same extent as the deeper tissues. Heating occurs as by means of dipole rotation and molecular distortion.

Dangers of Microwaves
Effects to Metal - As microwaves reflected from metal surfaces any metal placed on the tissue surface will act as a shield preventing radiations reaching the underlying tissues; this may lead to ineffective treatment. - Metal may also distort and concentrate the microwave filed causing local overheating which could be dangerous.

- If metal is so placed that it could reflect microwave energy into the tissues it is again possible that the overheating could occur. - Metal embedded in the tissues, due to accident or surgery, could also cause reflections into the tissues, which might lead to overheating. - However it is advisable to avoid treating the region of metal implants within the microwaves. Effects of Surface Moisture Perspiration must be allowed to evaporate freely. If moisture appears on the surface from any surface, e.g., open wounds or wet

dressings, it will absorb radiations, so treatment should be stopped and the moisture removed. Cardiac Pacemakers - This could be affected if the microwaves were directly applied to the region but there is little, if any, risk from scattered radiation. Eyes - Due to its structure the eye selectively absorbs microwaves and is not easily able to dissipate heat and thus can become overheated. - If the treatment is such that radiation may enter the eye, when treating the anterior aspect of the shoulder with a distance emitter for example, the patient should be given goggles which are impervious microwaves. - Such of goggles are of two kinds A metal mesh, which reflects practically all, microwave radiation but allows sufficient light between the mesh to see clearly. A thin layer of metal supported on glass, which again reflects, microwave radiations, but interferes little with visible light. - Closing the eyes would not prevent the transmission of microwaves but would diminish them. Testes - Small temperature rises can interfere with spermatogenesis, so treatment of microwave over testes is avoided. It is felt that heating of 100mW/cm could possibly produce testicular damage in humans; therefore direct irradiation of the testes should be avoided and care taken to prevent large amounts of reflected or scattered radiation reaching the region. - The testes are more susceptible because of their exposed position and possibly their structure. The same does not apply to the deeply placed ovaries, which are unlikely to be heated by microwave treatment. Pregnancy

It is recommended that microwaves should not be given to the pregnant uterus or patients attempting to pregnancy.

Circulatory Defects - Ischaemic areas should not be treated, because of the increased demand for oxygen, which results from the rise in temperature. - Patients at particular risk of hemorrhage, thrombosis, phlebitis, and other vascular lesions should not receive microwave treatment.

Morphological Effects
The shape of the tissues to which the microwave beam is being applied will have sufficient effects due to both reflection and refraction: There is considerable reflection of therapeutic microwave radiation from skin, which is greater when it is not being applied perpendicularly to the surface. Microwave radiation passing in the tissues will be subject to refraction as the wave velocity decreases from air to skin and fat and then to muscle. The radiations are bent towards the normal; hence converging and giving relatively greater heating than would otherwise occur.

Pictures of Microwave Diathermy

WHIRLPOOL BATH
History
The concept of the whirlpool bath has been around for thousands of years. As early as 2000 BC, the ancient Egyptians used a version of the whirlpool bath for therapy, with hot stones and swirling water to soothe aching muscles. And the ancient Greeks thought of bathing as more than just hygiene a bath in the Greece of 400 BC was a health measure and was touted as a cure for many diseases. The modern science of hydrotherapy owes much to the Greeks. On the other side of the world, around the same century, in Japan, the first onsen, or public hot spring, opened. Inns were built nearby these natural

hot tubs over the years, and indoor soaking tubs were added to help the tired traveler relieve their aches. These tubs, called ofuru, will pop up later on in our tale of the development of the modern whirlpool bath. The ancient Romans embraced the medicinal side of bathing even more so than the Greeks had. The construction of thermae, gigantic bathhouses that could hold thousands of bathers, pushed the per capita consumption of water up one-hundred-fold in Roman cities. When the Roman legions conquered foreign lands, one of the first buildings built was always a public bath, ruins of which can still be found near the natural thermal springs and mineral baths all over Europe and around the shores of the Mediterranean. After the fall of the Roman Empire, bathing fell into disrepute in Europe. However, public baths were still a big thing in the Ottoman Empire, famous over the past thousand years for the domed hammam, a style still evident in the Baths of Roxelana, built in 1556, with steam rooms, washing quarters, and massage platforms. But, for most of the rest of the world, bathing became more limited, often restricted to only those parts of the body seen in public, until the dawn of the Industrial Age, when regular work weeks and a Saturday night bath before dressing up the next day for Sunday worship became the norm for most of Europe and the Americas. Then came the Jacuzzi. In the late 1940s, in the state of California, in the United States, early versions of hot tubs were cobbled together from wine vats and large oak barrels scavenged from the regions innumerable wineries. The Japanese influx into California over the previous century provided part of that inspiration for these hot tubs with the Japanese ofuru. Custom tubs were made from California redwood, and, though leaky and hard to clean, these hot tubs became very popular up and down the Pacific coast.

Meanwhile, six immigrant brothers, the owners of a Berkeley factory that had begun as a manufacturer of airplane propellers in the 1920s, had moved on to the manufacture of large agricultural pumps. One of the brothers, Candido Jacuzzi, wanted to help his young son, who suffered from the chronic pain of rheumatoid arthritis. Candido was inspired by the hydrotherapy tubs used in the periodic treatment of his sons condition to develop a small submersible pump that could be placed in a bathtub. He found that the daily use of this small pump would give his son the same relief that he received in his notfrequent-enough hydrotherapy treatments at the hospital. In 1955, the Jacuzzi brothers began selling that pump, called the J-300, to schools and hospitals as a therapeutic aid. Orthopedists and physical therapists began prescribing the J-300 for personal use. In the early 1960s, the company decided to develop a consumer version of an integrated tub and pump. In 1968, the Jacuzzi brothers began selling a tubsystem complete with controls and water-jets; Hollywood celebrities began buying this home luxury appliance, the Jacuzzi. Fiberglass shells began to replace the original wooden slats of the Jacuzzi in 1970, and, not long after that, acrylic shells began to be used. Cleaning a hot tub became much easier, and hot tubs became that much more hygienic. From the 1970s on, better filters and improved control systems were installed in larger tubs that could accommodate more people, in order to satisfy the increasing popular demand for these appliances. The simple hydrotherapy bath has come to be known by many names: hydrospa, jetted bath, whirlpool bath, air-spa bath, and hydro-pool. Some tubsystems even included an ozone generator to add new levels of healthy invigoration to the whirlpool experience. Underwater lighting was been added to some baths for both aesthetic reasons and for the chromatherapy effects.

Whirlpool baths are available today in enameled steel or reinforced acrylic, with features that can be added or subtracted to fit any budget. Most whirlpools have self-draining pipes, and some even have built-in systems that will disinfect the most hidden area within the tub.

Definition
Whirlpool baths are stainless-steel tanks or baths of various sizes. The smaller ones are made to accommodate one limb, while larger ones allow the patient to sit. The whirlpool refers to turbulence produced by an electric pump, or compressed air, which mixes air and water into a jet stream. This water agitation can be varied in force by controls on the pump or (turbine) ad air pressure. The direction of the stream can be altered by changing the position of the output nozzle. A mixing tap allows any desired water temperature; temperature between 36 and 41C are usually employed.

General Description
- Indicated for partial - allows limited arm and leg exercises

Two General Types

A. Portable B. Fixed

Three of Whirlpool Baths

Extremity Tank- for treatment and legs (distal parts) High body/ Hip Tank for LE, required patient to flex hip and knee - The length does not allow full extension (limits amount off ROM)

- Greater body surfaces area to be submerge up to midthoracic region Low boy- not as deep as high boy but has greater length can fully extend the LE and perform full ROM

Measurement of Whirlpool WIDTH Ext Trunk High Boy Low Boy 15 20-24 24 LENGTH 28-32 (3) 36-48 (2) 56-56 (1) DEPTH 18-25 (2) 28 (1) 18 (3)

Precautions of Whirlpool
Check the temperature of the water before immersing the part. Avoid excessive pressure on the extremity from the sides of the tub by using a rolled towel. If bandages adhere to the wounds, let them soak first prior to removal. Make certain that point is strapped in when sitting in the high chair. Remove jewelry from the area to be treated. Practice proper draping to avoid getting the clothes wet. The room temperature should be higher than in other treatment areas in the PT department to avoid chilling the patient. Oral temperature should be monitored when heating a large body surface area. When treating ulcer and burns involving large areas, it is wise to use salt and prevent dehydration.

When using US together with WBP, the agitator must be turned off to prevent bubbles from interfering with heat transfer. Precautions against HIV should be exercised for all patients regardless of blood borne infection status with protective barriers (i.e. gloves, masks, gowns).

Tank status turbines are cleansed after each use.

Use of Whirlpool
Stimulation of circulation for wound care Promotion of relaxation and pain relief Removal of oxidants and necrotic tissue Facilitation of exercise, either assistance or resistance

Contraindications
All general contraindications in heating or cooling Febrile patients Poor sensation Edema

Temperatures Used
36.5C to 40.5C - 130C - 110F In general, except in PVD, sensory loss and full body immersion PVD, should be 10C above skin temperature to a maximum body to (95F -100F) Cardiovascular or pulmonary not exceeding 30C Debilitated px-94-98C

Durations
General whirlpool- 20-30 minutes

Debridement (necrotic tissue)- 5-20 minutes Active exercise -10-20 minutes

Most Contaminated Sites: (BOATED)

Bottom Overflow pipes Agitators Thermometer Edges Drains

Common Antibacterial Agents Disinfectant Used

Sodium Hypochlorite (Bleach)- dilution of 1.60 - 500ppm (1:00 dilution/1:20 dilutions) - Inactive HIV Chlorine (200ppm) effective in eradicating the pseudomonas Glutaradehydes formation, alcohol, ethylene oxide, beta propriodactonefor spore forming bacteria Povidone- iodine (.75% available iodine) Chloramine T (chloragene)- 100-200 ppm Effeftive gram negative organisms and pseudomona

Picture of Whirlpool Bath

SITZ BATH
Definition
Comes from the German word Sitzen, and means to sit. Sitting in water means to sitz, or sitting bath. Priessnetz, the Austrian who used water as a curative remedy, used the Sitz Bath in treating constipation and other abdominal and pelvic condition. A sitz bath is a form of bathing where the bottom and hips are immersed in warm or cold water for a period of time, 15 20 minutes is ideal. Warm sitz baths are best for cleansing the area while cool sitz baths help to ease swelling and can even help with constipation. Sitz baths will decrease inflamation of hemorrhoids as well as easing discomfort. Sitz baths can be used with water by itself or you can add other forms of solutions (such as lavender) to the water. A simple trick is to add salt or

baking soda to the water and allow you to soak in the water for 20 minutes. This trick works to clean the affected area as well as relieving pain. A sitz bath (also called a hip bath) is a type of bath in which only the hips and buttocks are soaked in water or saline solution. Its name comes from the German verb "sitzen," meaning "to sit."

History
The sitz bath originated in Europe a long time ago. The name comes from a german word sitzen which means to sit in English. Nowadays sitz baths are used as a form of pain relief and local cleansing for people who suffer hemorrhoids, abdomen cramps, anal fissures, yeast infections, and genital herpes.

Therapeutic Effects
Sitz bath is useful in treating any condition involving the rectum or pelvis. By this simple procedure muscle cramps and pelvic pain can often be relieved without having to use powerful drugs. Sitz baths are also useful in relieving urinary retention and spasms of rectum. The patient sits on a folded towel in a tub of warm water for a period of 15 to 30 minutes several times a day. The water should be at least six inches deep and the temperature somewhere around 110-120 degrees Fahrenheit. Some doctors like to give alternating sitz baths, using both hot and cold water, thus increasing the effectiveness of the treatment. Sitz baths are very beneficial following operations on the rectum for hemorrhoids, fissures. Fistulas and similar conditions. After such an operation the patient may be instructed to take several sitz baths every day and also during the night if necessary. These treatments are a real aid in healing the tissues. If the weather is cool, a blanket should be draped around the shoulders to prevent chilling. After the treatment the patient should return to bad for a time.

How to Take a Sitz Bath

1. Youll need a bathtub, shallow bucket or a sitz bath. The plastic sitz bath sits over a toilet and is recommended. Many of these plastic sitz baths come with the ability to continuously add warm water to the bath so it doesn't get cold. The overflow of the water goes into the toilet. You can buy a sitz bath at most drugstores - plastic sitz baths will cost around ten to fifteen dollars. 2. Fill up your bathtub, bucket or sitz bath with warm water. The water should be warm enough to be almost uncomfortable, but not warm enough to burn. The water should be just deep enough to cover your buttocks and hips. 3. In an optional step (some practitioners skip the cold water step), you can fill up another bathtub, bucket or sitz bath with cold water. If you're using the cold water sitz bath in addition to the warm, you'll want to move back and forth between the cold and warm water every few minutes. In her book Herbal Healing for Women, Rosemary Gladstone recommends moving back and forth between the waters five to six times, several times a week. 4. Most practitioners recommend sitting in the water for about 20-30 minutes several times a week to promote healing. 5. When you get out of your sitz bath, make sure you dry the area with a clean, cotton towel. You should pat, not rub dry. Some practitioners recommend letting the area air dry. 6. You can add salts to sitz baths if your doctor recommends it. This can be very helpful for vaginal or perineal discomforts in women (especially after childbirth). The amount of salt depends on the size of your sitz bath. Add enough salt to your sitz bath so that it easily dissolves.

7. Some women have found relief from vaginal yeast infections by adding vinegar to sitz baths. The vinegar makes the vaginal tissues an inhospitable home to the yeast. You should double-check with your doctor before attempting this or any other sitz bath recipe like an herbal bath, however.

Precautions
Some patients may become dizzy when standing up after sitting in hot water; it is best to have someone else present when doing a contrast sitz bath.

Description
The sitz bath is a European tradition in which only the pelvis and abdominal area are placed in water, with the upper body, arms, legs, and feet out of the water. The water can be warm or cool and one or two tubs may be used. Warm sitz baths are one of the easiest and most effective ways to ease the pain of hemorrhoids. A warm bath is also effective in lessening the discomfort associated with genital herpes, uterine cramps, and other painful conditions in the pelvic area. For prostate pain, patients should take two hot sitz baths a day, for about 15 minutes each. To ease discomfort from a vaginal yeast infection, women should take a warm saline sitz bath. To prepare; fill the tub to hip height with warm water and add 1/2 c of salt (enough to make the water taste salty) and 1/2 vinegar. Sit in the bath for 20 minutes (or until the water gets cool). The vinegar will help bring the vaginal pH back to 4.5 (pH is a measurement of how acid or alkaline a fluid is). A brief, cool sitz bath helps ease inflammation, constipation, and vaginal discharge. It can be used to tone the muscles in cases of bladder or bowel incontinence.

Other conditions respond to a "contrast bath" of both hot and cold. For this a patient should have a tub of hot water (about 110F/43C) and one tub of ice water. The patient should sit in the hot water for three to four minutes and in the cold for 30-60 seconds. This is repeated three to five times, always ending with the cold water.

If two tubs are not handy, the patient may sit in a hot bath (up to the navel). Then the patient stands up in the water and pulls a cold towel between the legs and over the pelvis in front and back. The cold towel is held in place for up to 60 seconds. Then the patient should sit back into the hot bath, and repeat the process 3-5 times, ending with the cold towel.

Preparation
The bath should be filled with 3-4 in (8-10cm) of water. For most conditions, nothing else should be added (no bubble bath or oil).

Aftercare
The area should be carefully patted dry and, if necessary, clean dressings should be applied.

Risks
Sitz baths pose almost no risk. On rare occasions, patients can feel dizzy or experience rapid heart beat because of blood vessel dilation.

Normal results
Swelling goes down; discomfort is eased; healing is promoted.

Picture of Sitz Bath

CONTRAST BATH
Definition
Contrast bath therapy, also known as "hot/cold immersion therapy, is a form of treatment where a limb or the entire body is immersed in ice water followed by the immediate immersion of the limb or body in warm water. This procedure is repeated several times, alternating hot and cold. Contrast baths are the immersion of a body part alternately in cold and hot water. This causes alternate contraction and dilation of blood vessels, which increase blood flow, white blood cell activity, and the oxidation process to speed up healing.

Therapeutic Effects
Contrast baths are frequently used in treatment programs for rheumatoid arthritis and complex regional pain syndrome I (CRPS I, reflex

sympathetic dystrophy).People with rheumatoid arthritis often benefit but may find simple warm water soaks as effective and less difficult. Patients with CRPS I may prefer to begin with less extreme bath temperatures. These patients also seem to benefit, but this improvement is difficult to separate from the effects of other desensitization and activity programs. Research is limited, but contrast baths may also improve autonomic regulation and blood pressure with hypertension.

Technique of Application
Contrast baths use two baths, one typically at 38C to 40C and the other at 13 C to 16 C, to produce reflex hyperemia and neurologic desensitization. Effectiveness is thought to be due to alternating exposure to heat and cold. Treatment typically begins with an initial soaking of the hands or feet in the warm bath for about 10 minutes and then proceeds to four cycles of alternate 1-to-4 minute cold soaks and 4-to- 6 minute cold soaks. If edema is an issue, a case can be made for ending with cool, rather than warm, soak. Contrast baths involve alternate immersion in hot and cold water producing marked hyperaemia of the skin. Such treatment will cause considerable sensory stimulation as the cutaneous hot and cold receptors are alternately activated. This stimulation is relatively vigorous because each time neural accommodation starts to occur the temperature stimulation is reversed. This strong sensory stimulation may act to suppress pain by means of the gate mechanism and account for the subjective relief of pain that occurs in many patients receiving this treatment. It is also considered by many that contrast baths will help to reduce local oedema by promoting alternate vasodilation and vasoconstriction.

Methods of application
Two suitably sized baths are filled, the hot at 40-45C and the cold at 1520C (water from the cold tap is usually in this cold range). It is usual to start

and finish with immersion in the hot water. The period of immersion in the hot water is longer- 3- or 4 min- while immersion in the cold water is kept to 1 min. this cycle is repeated three or four times so that the whole treatment lasts anything from 15 to 25 min. As initial hot immersion of 10 minutes has been recommended to achieve hyperaemia (Lehman and de Lateur, 1982). During the treatment the hot water will cool and the cold will be warmed, partly due to the transfer of the warm/cold wet limb from one bath to the other. It is therefore usually necessary to top up both baths during treatment. This is not a problem that arises with large volumes of water. A thermometer should be available to check the water temperature.

Mode of Transmission
Conduction

General Description
Consists of alternating immersion of the distal limbs in hot or cold

Treatment Temperatures
Hot 42-45C (Braddom)/ 40-45C (Wadsworth) Cold 8.5-12.5C (Braddom)/ 15C (Wadsworth)

Treatment Duration
Within 30 minutes (Braddom) Within 15 minutes (Wadsworth)

Treatment Procedure

1. Braddom Begin 10 minutes with hot Alternate with 1 minute cold and 4 minutes hot Ends with cold

2. Wadsworth Begins 3 minutes with hot and follow cold for 1 minute Repeat cycle with 3 times Ends with hot

Indications
Post traumatic swelling Pain due to swelling Chronic inflammation Rheumatological disease, Neuropathies or other pain syndrome, such as RSD Infections Congestive headaches Sprains, strains Poor circulation, indolent ulcers Osteoarthritis

Contraindications
Advanced PVD Arterial insufficiency Diabetes mellitus

Precautions
Loss of feeling in the feet or legs

Extreme peripheral vascular disease of the feet or legs Hemorrhages

Picture of Contrast Bath

PHONOPHORESIS
Definition

Phonophoresis is the movement of drugs through the skin into the subcutaneous tissues under the influence of ultrasound. Many drugs are absorbed through the skin only very slowly; high-frequency sonic vibration may accelerate this process. Such treatment has been in use since the early 1950s but not by many physiotherapists. It is also known as sonophoresis or ultrasonophoresis. Phonophoresis relies on perturbation of the tissues causing more rapid particle movement and thus encouraging absorption of the drug. The effects of phonophoresis are those of the particular drug employed, combined with ultrasound. In studies on various musculo-skeletal lesions it is difficult to separate these effects, but one study (Griffin et al., 1967) compared the clinical effects of ultrasonically driven hydrocortisone with ultrasound alone in over 100 patients. Some two-thirds of these, mainly osteoarthritis patients, benefited significantly from ultrasonically driven hydrocortisone, while just over a quarter had similar benefit from ultrasound alone.

Common uses of Phonophoresis

Muscle soreness Tendonitis Bursitis

Penetration of Phonophoretically driven Drugs

The depth to which drugs can be made is a matter of particular uncertainty. As occurs with iontophoresis, once the drug has passed through the epidermis it is likely to be dispersed in the circulation to an extent which depends on the vascularity of the tissues concerned and the ease with which molecules of the drug can enter blood vesels. In any case dispersion will occur in the tissues. However, several studies quoted by Skauen and Zentner (1984) showed that cortisol could be driven into pig muscle and nerve by phonophoresis; further the therapeutic effects reported by several studies, e.g.

Kleinkort and Wood (1975), could only result if significant quantities of antiinflammatory drug had penetrated to the affected tissues. In some of these studies ultrasonic frequencies rather than lower those customarily employed, 0.33 or 0.25 MHz, were found to be more effective. In fact, it has been concluded that lower frequencies lead to greater penetration (Skauen and Zentner, 1984). It must be realized that deeper penetration does not necessarily infer greater effectiveness. If the therapeutic effects occur in the dermis and epidermis, such as the cutaneous anaesthetic effect of lignocaine, then it might be expected that higher frequencies would be a more effective delivery system since the ultrasound energy is largely absorbed in the superficial tissues. This has been shown to occur in that 1.5 and 3 MHz ultrasound appeared to be more effective in achieving absorption of local anaesthetic than 0.75 MHz (Benson et al., 1988). Interestingly, this same study showed that pulsed was rather more effective than continuous ultrasound in achieving transfer of this particular cream. Not only did the 1:1 pulsing used was lower than that given with continuous ultrasound. The fact that pulsing can lead to better penetration is good evidence for a specific effect due to pulsation of ultrasound.

Drugs Used in Phonophoresis

The anti-inflammatory drug hydrocortisone has been widely used and reported on; it seems that high concentrations of the drug are effectively driven through the skin with high-dosage ultrasound and the amount is proportional to the time and the intensity of treatment. However, low concentrations and lowintensity ultrasound seem to be less effective or ineffective (Skauen and Zentner, 1984). Kleinkort and Wood (1975), found 10% hydrocortisone ointment to be more effective than 1 %. Many in recent careful study comparing hydrocortisone phonophoresis with simple ultrasound (Holdsworth and Anderson, 1993), which included evaluation of an epicondylitis clasp, were unable to demonstrate any statistically significant difference between the

treatments. In this study, all patients received ultrasonic treatment and the vast majority of acute lesions appear to have benefited. It is possible that ultrasound having a pro-inflammatory effect and steroids an anti-inflammatory effect is conflicting therapies. Numerous other steroid-type drugs can be applied by phonophoresis as well as many non-steroidal anti-inflammatory drugs,mainly salicylates. An anti-inflammatory, analgesic cream (trolamine salicylate) has been recommended. A study to investigate the effectiveness of this agent on delayed onset muscle soreness in normal subjects (Ciccone et al., 1991) found that ultrasound alone increased the symptoms, while ultrasound with trolamine salicylate had no such effect. It was concluded that the anti-inflammatory activity of this drug was able to offset the increased soreness due to ultrasound. Phonophoresis of hydrocortisone has been used in the treatment of many skin conditions including psoriasis, scleroderma and pruritis. It would seem to be a simple, sensible and logical way to increase the rate of absorption of the drug into the dermis. A lotion containing zinc oxide, tannic acid, urea and menthol has been applied by phonophoresis to treat herpes simplex virus type II in both oral and genital infections with good results (Fahim, 1980). Antibiotics such as penicillin have been given by phonophoresis for the treatment of skin infection. Some suggested products appear not to be transmitted; e.g. Difflam Cream (benzydamine hydrochloride). This was tested in a double-blind controlled study (Benson et al., 1989) in which the drug in a gel was recovered from the skin surface and measured; no significant difference was found between treatments with the ultrasound on and those with it off. As suggested above, if the base, cream or ointment in which the drug is dissolved is not a good ultrasonic transmitter then it seems unlikely that treatment would work effectively. Cameron transmission of and Monroe (1992), in who in their article discuss the a ultrasound phonophoretic media, recommended

qualitative evaluation of ultrasound transmission by fixing wide, sticky tape round the face of the transducer to produce a 1 cm well. The substance to be tested is placed on the transducer surface and the remainder of the well filled with water. If the medium transmits ultrasound, the water will be agitated at intensities of 1-2W/.

Application
The drug to be driven into the tissues is combined in a suitable gel or cream which forms the couplant. It is smeared onto the part, using a spatula so that it is not applied to the physiotherapists fingers, and some may be smeared onto the treatment head. The treatment head is moved over the skin in the usual manner. Realtively high intensities of 1 and 1.5W/ have been used. The depth of the target tissue determines the frequency used. The time of treatment depends on the area over which phonophoresis is to be applied; 1min treatment for every 10 cm area is reasonable, although Griffin et al. (1967) suggest 5 min for each 25 cm, i.e. about 1 min for 30 cm. Most reported applications of phonophoresis have used continuous ultrasonic and pulsed energy to produce skin anaesthesia with Emla cream; the pulsed mode appeared to be more effective in these circumstances. When treatment is completed the remaining couplant, containing the drug, should be removed from both the patients skin and the ultrasound transducer. It is essential to ensure complete removal from the treatment head since any drug remaining may be inadvertently and inappropriately applied to the next patient treated. Since the cream or gel containing the drug is being used as the couplant it is important that it transmits ultrasound adequately. This has been considered by Benson and McElnay (1988; 1994), who investigated the transmission characteristics of a large number of different products and found wide variations. In general they found that gels were more efficient coupling

agents than creams, particularly for higher (1.5 and 3 MHz) frequency ultrasound. Several were poor transmitters.

Contraindications
The same considerations apply when giving phonophoresis as apply when giving ultrasound for its intrinsic effect. The effect of the drug must also be considered; for example, anti-inflammatory drugs may suppress necessary inflammatory reactions, such as local skin infections, allowing them to become more serious. If local anaesthetizing drugs are being driven in by ultrasound it must be remembered that skin sensation under the treatment head will gradually be lost so that the patient may no longer detect excessive heat; high intensities should not therefore be used for these drugs.

Picture of Phonophoresis

TRANSCUTANEOUS ELECTRICAL NERVE STIMULATOR

Definition
The term transcutaneous electrical nerve stimulation in its widest sense refers to the application of electrical currents to stimulate nerves. However, the term is almost exclusively applied to the use of small, portable electrical stimulators to treat pain.

History
The gate theory postulated in 1965 that cells in the substancia gelatinosa are stimulated by both nociceptive and sensory signals and as gates by inhibiting the passage of nociceptive information to the brain if sensory afferent signals are present. Transcutaneous electrical nerve stimulation (TENS) provided sensory afferent signals and, after some successful trials, became widely accepted. The mechanism of action of TENS remains controversial. Thus, although research shows that stimulation reduces dorsal horn cell activity. The gate theory does not explain phenomena such as painless sensory neuropathy, analgesia persisting after stimulation, and delayed onset of analgesia. As a result, other explanations, such as those involving frequency dependent effects and central nervous system endorphins, have been advanced.

Indications
Chronic pain Acute pain

Intractable pain (TENS can provide adequate relief of pain secondary to malignancy. Results are best with trunk and extremity pain and worst with pelvic and perineal pain).

Rehabilitation: the use of TENS for the reduction of pain during rehabilitation can increase performance and shorten disability. Care must be taken to not allow the TENS to obliterate pain to the extent that the patient loses protective cues and overstresses the part being rehabilitated.

Trigger spots in myofascial pain syndrome Stress continence Haematoma Chronic ligamentous lesion Delayed union and Sudecks atrophy

Contraindications
Pacemakers Carotid nerve stimulation Laryngeal stimulation During pregnancy During menstruation Febrile condition Dermatological condition Malignant tumors Danger of hemorrhage Deep vein thrombosis Infective condition

Methods of Application
Metal plate electrodes and pads

Quadripolar plates Suction cup Quadripolar probe

Precautions
1. Burns Bare metal electrodes Skin currents Increased intensity Unmoist (dry) pads

2. Haematoma 3. Poor Results Faulty positioning of pads Poor balancing of the circuits Incorrect choice of frequencies

Advantages
Larger dose can be given Decrease skin sensation is not a contraindication Current can be localized Metallic implants can be treated Referred pain is an indication

TENS Electrode Placement

Electrode placement is one of the most critical factors for the success of TENS. Directly or around the painful site Over trigger points Over acupuncture points Within a specific dermatome

At the site of the corresponding nerve root The most significant The most significant complication of TENS is local skin rashes produced by the conduction of gel or tape. There are no contraindications to 24- hour use of high TENS however, should be used only 30-40 minutes at a time, as Low TENS causes muscle contraction and may cause soreness if used for longer periods.

Electrodes should be removed everyday to clean the skin and inspect the area.

Physiologic Effects
1. Frequency range Stimulate motor nerves 1-10 Hz Vasodilation 100 Hz Edema 1-100 Hz rhythmic Analgesic 1-100 Hz

2. Rhythmic or Constant 3. Dosage Intensity subjective Frequency and Duration

Picture of TENS

JOBST INTERMITTENT MACHINE

Definition
These are pneumatic (air) units which apply external pressure on edematous parts These pumps stimulate the function of the physiological muscle pump (venous system) (lymphatic system. Without movement of the muscle or joint) It is similar to the milking action of massage technique: Kneading

Effects of Jobst
Removal of the exudate/metabolites excess fluids in the direction of venous and lymphatic system. Must be done also with thera ex, massage and elevation

Compression
Through intermittent deflation and inflation

Two Parameters
1. Amount of pressure applied: F/A 2. Cycles of inflation and deflation

Pressure applied
Must be below the diastolic pressure 40-60 mmHg for arm 60-100 mmHg for leg cycles 3:1 (45-60-90 sec)

Duration of Treatment
Severe oedema: 8 hours/day (3-4 hours in AM and 3-4 hours in PM) Mild Oedema: 30 minutes 1 hour

Contraindications
Acute DVT Arterial insufficiency Infections at treatment site Cardiac and renal edema Metastasis

Picture of Jobst Intermittent Machine

INFRARED RADIATION
Definition
Infrared therapy is delivered using a lamp that that produces (wideband) infrared electromagnetic radiation (3000-5000nm), which may be either luminous or non-luminous (i.e. radiation may be visible, emitting some visible red radiation, invisible). Such lamps are usually floor- standing units incorporating a main- supplied base controller unit to regulate output, and a radiator and reflector on the end of an adjustable arm. As for heat packs, skin testing prior to infrared treatment is required to all cases. For treatment the relevant anatomical area is exposed and the patient carefully positioned relative to the reflector of the treatment unit, to ensure that the incident infrared radiation strikes the target tissue perpendicularly, thus minimizing reflection. Treatment times depend on a variety of factors, including the power output of the unit, although in most cases the treatment period will not exceed 20 minutes. While most physiotherapy departments will have at least one infrared unit, they are perhaps not as widely used as in previous years due to the relative ease of application of alternative forms of heating.

Physical Characteristic of Infrared Radiation

Infrared (IR) Radiations lie within that part of the electromagnetic spectrum which gives rise to heating when absorbed by matter. The radiations are characterized by wavelengths of 0.78-1000m, which are between those of microwaves and visible light. Many sources which emit visible light or ultraviolet (UV) radiation also emit IR.

Physical Behavior of Infrared Radiation

Infrared radiations can be reflected, absorbed, transmitted, refracted and diffracted by matter, the reflection and absorption being of most biological and

clinical significance. These effects moderate the penetration of energy into the tissues and thus the biological changes which take place.

Physiological Effects
Nerve stimulation Vasodilatation Phagocytosis Pigmentation and erythema Sweating Blood pressure Increases metabolic rate

Therapeutic Effects
Pain relief Reduces muscle spasm Acceleration of healing and repair

Indication
Pain and muscle spasm Edema Healing of wounds and chronic suppurative areas

Precautions
Burns Skin irritation Lowered blood pressure Areas of defective arterial blood flow Eye damage Dehydration

Contraindications
Impaired cutaneous thermal sensation Defective arterial cutaneous circulation Patients whose level of consciousness markedly lowered by drugs or disease Acute skin disease Subjects with advance cardiovascular disease Tumor of the skin may be stimulated to increase growth Acute febrile illness Skin damage due to x-ray therapy or other radiation Defective blood pressure regulation Deep X-ray Topical creams and oils Dermatological conditions Age Metal

Application
Preparation of apparatus Preparation of patient Examination and testing Setting up right angle, distance -60- 75 cm, 45-50cm-small lamp Instructions and warnings Application Termination of treatment

Advantages
Maybe used to large body parts

Maybe used to treat patients who cannot tolerate weight Produces soothing and gentle heat which promotes relaxation Maybe used areas with open wounds and tom dry seeping wounds No contact with patient-less infection risk Area being treated maybe observed

Disadvantages
Not easily localized to a specific treatment area Causes skin dryness Dry heat maybe agitating and irritating to some patients Luminous lamps produces glare which may be irritating to the eyes Needs close and constant monitoring of duration of application and proper positioning of patient and equipments to avoid burns Difficult to ensure consistent heating of irregular surfaces since heat transfer depends on distance and angle of source to skin

Things to remember during IRR application

Never position the IRR lamp directly over the patient or the part to be treated Distance should be approximately.45 to .6 meter Remove surface metals from the area being treated

Picture of Infrared Radiation

ELECTROMYOGRAPHY
Definition
Electromyography (EMG) measures the response of muscles and nerves to electricalactivity. Its used to help determine muscle conditions that be causing muscleweakness, including muscular dystrophy and nerve disorders. Electromyography is the study of motor unit activity. Motor units are composed of one anterior horn cell, one axon, its neuromuscular junctions, and all the muscle fibers innervated by that axon. The single axon conducts an impulse to all its muscle fibers, causing them to depolarize at relatively the same time. This depolarization produces electrical activity that is manifested as a motor unit action potential (MUAP) and recorded graphically as the electromyogram. It is often reassuring to a patient to realize that EMG only records electrical activity already present contracting muscle, as opposed to introducing electrical energy into the body. Electromyography involves detecting, amplifying and displaying electrical changes that occur when muscle contracts. The signals are tiny, a few microvolts, but are amplified about a thousand times to give milliviolt values that can be displayed on an oscilloscope, operate a loudspeaker and be recorded on a chart.

History
Luigi Galvani presented the first report on electrical properties of muscles and nerves in 1791. He demonstrated that muscle activity followed stimulation of neurons and recorded potentials from muscle fibers in states of voluntary contraction in frogs. This information was disregarded for close to a century, as conflicting theories were accepted, and did not become part of medical technology until the early part of this century, when instrumentation was developed to make recording such activity reliable and valid. Today

electromyography (EMG) is used to evaluate the scope of neuromuscular disease or trauma, and as a kinesiologic tool to study muscle function. As an assessment procedure, clinical electromyography involves the detection and recording of electrical potentials from skeletal muscle fibers. Nerve conduction velocity (NCV) tests determine the speed with which a peripheral motor or sensory nerve conducts an impulse. Together with other clinical assessments, these two electrodiagnostic procedures can provide information about the extent of nerve injury of muscle disease, and the prognosis for surgical intervention and rehabilitation. These data can be valuable for diagnosis and determination of rehabilitation goals for patients with muscuskeletal and neuromuscular disorders. Kinesiologic EMG is used to study muscle activity and to establish the role of various muscles in specific activities. Although the concepts are the same, the focus of kinesiologic EMG is quiet different from the clinical EM, in terms area. of instrumentation requirements and data analysis techniques. Basmajian and De Luca have provided a thorough review of literature of this

Procedure
For the purpose of EMG, a needle electrode is inserted into the muscle (the insertion of the needle might feel similar to an injection). The signal from the muscle is then transmitted from the needle electrode through a wire (or more recently, wirelessly) to a receiver/ amplifier, which is connected to a device that displays a readout. The results are either printed on a paper stripper, more commonly, on a computer screen.

What can EMG Diagnose?

EMG can diagnose three kinds of disease that interfere with normal muscle contraction:

Diseases of the muscle itself (most commonly muscular dystrophy in children). Diseases of the neuromuscular junction, which is the connection between a nerve fiber and the muscle it supplies. Diseases upstream in nerve roots (which can be due to either nerve damage or ongoing nerve injury)

Normal Values
Muscle tissue is normally electrically silent at rest. Once the insertion activity (caused by the trauma of needle insertion) quiets down, there should be no action potential on the oscilloscope. When the muscle is voluntarily contracted, action potentials begin to appear. As contraction is increased, more and more muscle fibers produce action potentials until a disorderly group of action potentials of varying rates and amplitudes (complete recruitment and interference pattern) appears with full contraction.

Abnormal Values
Disorders or conditions that cause abnormal results include the following: Polymyositis Denervation (reduced neuron stimulation) Carpal tunnel syndrome Amyotropic Lateral Sclerosis (ALS) Myopathy (Muscle degeneration, may be caused by a number of disorders, including muscular dystrophy) Myasthenia gravis Alcoholic neuropathy Axillary nerve dysfunction Beckers muscular dystrophy

Brachial plexopathy Cervical spondylosi Dermatomyositis Distal median nerve dysfunction Duchenne muscular dystrophy Facio-scapulohumeral muscular dystrophy (Landouzy-Dejerine) Familial periodic paralysis Femoral nerve dysfunction Friedrichs ataxia Guillain-barre Lambert-Eaton syndrome Moroneuritis multiplex Mononeuropathy Peripheral neuropathy Radial nerve dysfunction Sciatic nerve dysfunction Sensorimotor polyneuropathy Shy-Drager syndrome Thyrotoxic periodic paralysis Tibial nerve dysfunction Ulnar nerve dysfunction

Risks
Bleeding (minimal) Infection at the electrode sites (minimal)

Special Consideration

Trauma to the muscle from EMG may cause false results on blood tests (Creatinekinase), a muscle biopsy or other tests.

Picture of Electromyography

BIOFEEDBACK
Definition
Bio means life. Feedback means returning the knowledge to origin. Then biofeedback means returning the biological knowledge created by the origin to origin in order to make the origin understand and control that knowledge. According to Grolier Encyclopedia, BF is to learn and control the physiologic functions of the body. The physiological functions of the body are not only related to the voluntary (For example heart rate). As a comprehensive definition, BF is a group of therapeutic procedures that uses electronic or electromechanical instruments to properly measure, process and feedback to patients in the form of auditory and/ or abnormal neuromuscular and autonomic activity. BF is used to help patients develop greater awareness of and an increase in voluntary control over their physiological processes that are otherwise involuntary and unfelt events by first manipulating the displayed signals and then by using internal psycho physiological cognitions to prevent, stop, or reduce symptoms (Schwartz and Schwartz 2003). BF can be very important and helpful in clinical situations where therapeutic exercise is indicated. BF measures and shows the physiopathological events that are unfelt normally and lets the patient regulate the disorders by creating awareness. That means BF achieves knowledge where this information cannot be taken by any conventional exercise. When a feedback signal warns the patient, augmentation of the motor performance will be better. BF is often used in physiatry and psychiatry. Psychiatrists find BF useful for general relaxation and especially in tension headache and anxiety. In physiatry BF has been used in a wide range of clinical conditions such as motor weakness, balance and gait disturbances, spasticity, neurogenic bladder and bowel dysfunctions, speech and swallowing problems.

History
Biofeedback has matured from its early cult cure- all days to its current status as a legitimate adjunctive technique for specific neuromuscular and behavioral disorders. Biofeedback can be used to inform the patient about movement, muscle activity, whole-body balance, force joint displacement, skin temperature, heart rate, blood pressure, or other physiologic information by amplifying and displaying this information so that the patient can learn to control these. To quote Johm Basmajian, biofeedback is a technique to reveal to human beings some of their internal physiological events, normal and abnormal, in the form of visual and auditory signals in order to teach them to manipulate these otherwise involuntary or unfelt events by manipulating the displayed signals. Most often, biofeedback techniques are used for the patient who has difficulty accessing the information through normal physiolic mechanisms such as proprioception or visual cues.

General Principle
The goal of biofeedback in physical therapy is to improve motor performance by facilitating motor learning. To use biofeedback correctly and effectively, therapists must understand the principles of motor learning and the technical limitations of biofeedback machines.

Physiologic Feedback
The fastest cortical feedback circuits, (i.e., those which could take into account changes in environmental conditions) have at least 100-200-msec latencies. For example, a pianist performing a fast run cannot possibly rely on visual or auditory feedback during the run. The performance is therefore open-loop if a mistake is made, several notes will be played before the performer is even aware that the mistake has occurred and several more notes will be played (i.e., about 0.2 sec of music) before any adjustments to the motor plan can be made.

Ambulation also requires a series of preplanned motor events. If a disruption occurs, feedback of the mistake can only be acted upon and built into the plan for ensuing steps. Normal walking cadence is about 1 cycle per second. Ankle dorsiflexors, for example, must resist foot slap from heel strike to foot-flat for about 60 msec. Therapists attempting to encourage normal gait in patients with hemiphlegia by using feedback from dorsiflexor EMG should not, therefore, ask a patient to correct inadequate dorsiflexor motor unit activity within each gait cycle; the information to be given is merely that EMG activity was inadequate during the past gait cycle. The therapist and patient must determine the correct neurophysiologic strategy to increase dorsiflexor motor unit activity in anticipation of ensuing heel strikes.

Biofeedback in Rehabilitation
When using biofeedback, the patient must: 1. Understand the relationship of the electronic signal to the desired functional task. 2. Practice controlling the biofeedback signal, and 3. Perform the functional task until it is mastered and the patient no longer needs the biofeedback. Biofeedback techniques thus require that patients engage in closed-loop learning, using ongoing feedback, until motor skills develop sufficiently so that open-loop movement (where feedback is required) can be accomplished. Winstein and others have shown that the combination of open and closed-loop learning, called scheduled feedback, can be more effective than closed-loop, classic biofeedback. In scheduled feedback paradigms, subjects practice the task initially with feedback following each trial, then spend increasingly long practice periods without feedback following each trial. Apparently, scheduled feedback encourages subjects to rely upon normal,

internal feedback mechanisms and decreases their dependence on relatively unnatural biofeedback. Conventional neuromuscular reeducation is based heavily upon

providing patients with helpful comments (feedback) to assist their recovery of previously acquired skills. The therapists job, often, is to focus the patients attention on the underlying motor programs and biomechanical schema required to recoup those skills. If a postmeniscectomy patient cannot execute a straight-leg raise, for example, the gait rehabilitation will be impeded, and the therapist usually prescribes quadriceps-setting exercise. Biofeedback=-assisted quad-setting, however, might improve the patients information processing and result in more rapid rehabilitation by augmenting knee joint or quadriceps proprioception with electronic feedback and supplementing the normal feedback inhibited by the meniscectomy. If the patients normal proprioception and other physiologic mechanisms are disrupted, normal skills is restricted. Biofeedback is simply one technique that therapists may employ to help convey their message about motor programs and biomechanical schema to the patient. Biofeedback can assist the rehabilitation process by: 1. Providing clear goal (motor behavior or outcome) that the patient should achieve. 2. Permitting the therapist and patient to experiment with various strategies (processes) that generate motor patterns to achieve the goal. 3. Reinforcing appropriate motor behavior. 4. Providing process- oriented, timely, and accurate knowledge of results of the patients efforts. By attending to the biofeedback signal, the patient can close the loop. Some patients become more motivated when biofeedback is employed because they know the machine will not be falsely encouraging. Both the therapist and

the patient must therefore understand the meaning of the feedback signal and appropriate goals must be agreed upon. The therapist must explain what the machines signals mean to the patient, and what constitutes success. The machine should be set to give auditor or visual feedback that corresponds to the motor behavior desired. For example, if spastic antagonist muscles are monitored, the patient should be instructed to decrease the EMG activity; the biofeedback device is set to flash a light signal accomplishment of this goal. Alternatively, an electrogoniometer might be employed that changes the pitch of a buzzer as the joint is moved in the proper direction.

Relevance
Useful information is pertinent to the desired motor outcome: neither too little information should be given, nor the information should be immediately applicable to the behavior. Although therapists may verbally describe the location of agonist and antagonist muscles, and even make attempts to describe the feelings patients should experience if the muscles are used appropriately, there is no way to communicate which motor units to activate. Electromyographic biofeedback can provide relevant information regarding motor unit that patients do not otherwise have available.

Picture of Biofeedback

BIBLIOGRAPHY
Electrotherapy Explained, Principles and practice (2 nd Edition) John Low BA (Hons), FCSP, Dip TP, SRP Ann Reed BA, MCSP, DipTP, SRP http://amazinghealth.com/contrast-baths http://books.google.com.ph/books?id=mpcAXLniDykC&printsec=frontcover&dq=electrother apy&hl=en&ei=5u1MTp7_KsXomAWCg4nKBg&sa=X&oi=book_result&ct=book-thumbna http://www.homeinteriors.co.uk/bathrooms/bathroom-info/whirlpool-bath/the-history-ofwhirlpool-baths http://medical-dictionary.thefreedictionary.com/sitz+bath https://sites.google.com/site/activecarephysiotherapyclinic/system/app/pages/search?q=PH ONOPHORESIS&scope=search-site http://www.modernguidetohealth.com/home-remedies-treatments/sitz-bath.html http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1478902/pdf/brjsmed00032-0006.pdf http://www.orthonc.com/node/2347/done?sid=1196#patient-informationpatientformssubscribe-osnc-newsletter http://www.scribd.com/doc/49528195/Microwave-Diathermy IQ Physical and occupational Therapy Reviewer (revised Edition) Joy Y. Catabian, PTRP and Dominguez R Gomez, PTRP, RPT Physical Medicine and Rehabilitation, Principles and Practice (4 th Edition) Lippincott Williams and Wilkins