The Immortality is yours take it---Aquiles
INSTRUMENTATION AND MEASUREMENTS IN THE HUMAN BODY1
Bayoán R. Ortiz, Xavier Piñero and Joel Blanco 2
Abstract---One of the major contributions of biomedical
engineering to the life sciences and clinical medicine has
been in biomedical instrumentation. Advances in this
field have resulted in the development of new types of
biomedical instruments and the development of
numerous clinical approaches, such as electronic patient
monitoring, an important aspect of critical care
medicine, as well as a variety of devices to assist
individuals with disabilities.
Key Words---Classification of Biomedical Instruments,
Nervous System, Cardiovascular System, Respiratory
System, Endocrine System, Measurement Techniques,
Medical Measurement Constraints.
INTRODUCTION
Fluids compose over 80 percent of the human body. There
are many kinds of instruments to measure fluids in the
body. NASA and other care agencies around the United
States helped in the design of instruments. Each measuring
instrument has the characteristics of capacity, accuracy,
error, precision, linearity, and durability, simplicity of
operation, output, calibration, and cost. The purpose of
medical instrumentation is the measurement of
physiological variables: electrical activity of the heart,
respiratory airflow, blood pressure, etc. Measurement
techniques can be studied separately for each organ system,
such as the cardiovascular, pulmonary, nervous, and
endocrine systems. This approach isolates all important
measurements for specialists who need to know only about
a specific area, but it results in considerable overlap of
quantities sensed and principles of transduction [2].
THE HUMAN EYE
The response of differences in absorption. cones is not all-
or-none. Light of a given wavelength (color), say 500 nm
(green), stimulates all three types of cones, but the green-
absorbing cones will be stimulated most strongly. Like rods
1
This review article was prepared on July 10, 2004 for the
course on Fluid Mechanics, INGE 4015. Course
Instructor: Dr Megh R., Goyal, Professor in Biomedical
Engineering, General Engineering Department, PO Box
5984, Mayaguez, Puerto Rico 00681-5984. For details
contact: Email: m_goyal@ece.uprm.edu or visit at:
http://www.ece.uprm.edu/~m_goyal/home.htm
2
Authors are in the alphabetical order.
3
The numbers in the brackets refer to the refernce in the
bibliography with cited page.
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
the absorption of light does not trigger action potentials but
modulates the membrane potential of the cones [9].
The Schirmer strip test
In Schirmer test, we measure the quantity of tears that are
produced by the eye. If the tears are collected for some
time, lets say 5 minutes or so, then one can determine
whether the amount produced is sufficient for maintaining
eye health or not. If not much tears are produced, then one
have a tear deficient dry eye. If one produce enough tears,
but still have symptoms of ocular discomfort, then one may
have evaporative dry eye for example due to blepharitis or
Rosacea.
In Schirmer test a 35 mm x 5 mm size filter paper strip is
used to measures the amount of tears that are produced over
a period of 5 minutes. The strip is placed at the junction of
the middle and lateral thirds of the lower eye lid. The test is
done under ambient light. The patient is instructed to look
forward and to blink normally during the course of the test.
A negative test (more than 10 mm wetting of the filter
paper in 5 minutes) means you produce normal quantity of
tears. Patients with dry eyes have wetting values of less
than 5 mm in 5 minutes. An important limitation of
Schirmer test is that there may be considerable variability
in the results of tests done at different times and by
different doctors. So whereas this is perhaps the most
common dry eye test performed, its main utility may really
be in diagnosing patients with severe dry eyes. Sequential
tests to follow the course of a patient with mildm dry eye
may not be of value. There is one point of some debate in
Schirmer I test. When an anesthetic eyedrop is not used
then this test is thought to measure the basal + reflex tear
secretion. When an anesthetic eyedrop is used then this test
is thought to measure only the basic tear secretion.
There is compelling reason to believe that the tears
measured by these two different methods may not
sufficiently differentiate between basic and reflex tear
production. Most clinicians perform this test after using
anesthetic eyedrops to numb the eye. However, The
National Eye Institute workshop on dry eyes recommended
not to use anesthetic eyedrops before performing this test.
The cutoff value is similar whether or not anesthetic is
used. To measure the reflex tear secretion Schirmer II test
may be performed. Schirmer II test is performed by
irritating the nasal mucosa with a cotton-tipped applicator
prior to measuring tear production. Many clinicians regard
the Schirmer test as unduly invasive and of little value for
mild to moderate dry eyes. Other less invasive methods to
assess the adequacy of tear production have been
developed. The Phenol red thread test is one such test and
is commercially available (zone-quick).
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Figure 1. Red thread test [16].
A cotton thread impregnated with phenol red dye is used.
Phenol red is pH sensitive and changes from yellow to red
when wetted by tears (Figure 1). The crimped end of a
70mm long thread is placed in the lower conjunctival
fornix. After 15 seconds, the length of the color change on
the thread - indicating the length of the thread wetted by the
tears -is measured in millimeters. Wetting lengths should
normally be between 9mm and 20mm. Patients with dry
eyes have wetting values of less than 9 mm.
The Non-Contact Tonometer
The non-contact tonometer is an applanation tonometer and
works on the principle of a time interval. Measuring the
time it takes from the initial generation of the puff of air to
where the cornea is exactly flattened (in milliseconds) to
the point where the timing device stops. It takes less time
for the puff of air to flatten a soft eye than it does a hard
eye [35].
Figure 2. How non-contact tonometer works [35].
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
Figure 3. Non-contact tonometer [33].
The Applanation Tonometer
The pressure within an elastic-walled sphere or cylinder
such as the eye, an artery, or the pregnant uterus can be
measured from outside the walls by the use of an
applanation tonometer (Figure 4). This may be a
mechanical device consisting of a flat ring in which there is
a concentric disc maintained flush with the surface of the
outer ring but connected to a force transducer. When a
section of the wall is flattened by the device the pressure
required on the central disc to keep the wall flat is equal to
the pressure within the sphere or cylinder. The pressure is
calculated as the force applied divided by the area of the
inner disc. Large devices of this type are commonly used to
measure the intra-uterine pressure during labor. This device
is sometimes called a tocodynamometer or guard ring
tocograph, and the measuring instrument called a
cardiotocograph, which also records heart rate. Smaller
devices have been used for measuring pressures within
arteries and also within the eye by direct application to the
cornea [25].
Figure 4. Applanation tonometer [40].
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Figure 5. Schiotz tonometer [25].
Indentation (Schiotz) tonometer
This type of tonometer uses a plunger to indent the cornea.
After placing a drop of anesthesia on the eye to numb its
surface, the doctor carefully places the instrument directly
on the cornea. The pressure within the eye is determined by
measuring how much the cornea is indented by a given
weight. This test is less accurate than applanation
tonometry and is less commonly used today by
ophthalmologists and optometrists. However, other health
professionals (such as family practice doctors or urgent
care doctors) may still commonly use this test [11].
Figure 6. PanOptic Ophthalmoscope [27].
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
PanOptic Ophthalmoscope [27]
1. Makes it easy to enter small, undilated pupils
2. Provides a 5X larger view of the fundus than ever
before achieved with a standard ophthalmoscope
in an undilated eye
3. Enables a 25º field-of-view vs. the standard 5º
field-of-view
4. Increases magnification by 26% over a standard
scope
5. Greater working distance between practitioner
and patient improves comfort for all
6. Affordable new head is compatible with all
existing Welch Allyn 3.5V battery handles and
wall transformers [27].
The Biomicroscopy
Ultrasound biomicroscopy (UBM) can provide high-
resolution images in the living human eye; this resolution
has been compared to microscopic resolution. This system
is particularly useful in studying the anterior segment and
analyzing the different types of glaucoma. Anatomical
aspects, physiopathological processes and surgical results
in glaucoma could be evaluated with UBM. This
exploration is also important in determining differential
diagnosis, risk factors, and prognostic elements. In
addition, using UBM after filtering surgery helps detect
early complications and understand poor surgical outcome.
THE HUMAN EAR
The human ear serves as an astounding transducer,
converting sound energy to mechanical energy to a nerve
impulse which is transmitted to the brain (Figure 7).
Figure 7. Human ear [23].
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The ear's ability to do this allows us to perceive the pitch of
sounds by detection of the wave's frequencies, the loudness
of sound by detection of the wave's amplitude and the
timbre of the sound by the detection of the various
frequencies which make up a complex sound wave.
The ophthalmoscope and otoscope
Due to the halogen illumination, this ophthalmoscope
provides a clean white light for optimum examination of
the eyeball. As with the otoscope, the on/off switch has
been cleverly designed into the stainless steel pocket clip to
provide easy operation with either hand.
The lens wheel has a range of 0 to +20 and 0 to -20
dioptres. A full set of apertures are also provided - main
beam, small beam, semi circle, green filter and a fixation
star. There is also a built in dust cover made of repeated
unsealed glass to prevent dirt entering the head. The glass
protection is made of silicon.
As with the otoscope the smooth finish of the overall unit
affords easy cleaning and maintenance [31].
Figure 7.: Ophthalmoscope (left) and otoscope (right) [36].
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
RESPIRATORY SYSTEM
The primary function of the respiratory system is to supply
the blood with oxygen in order for the blood to deliver
oxygen to all parts of the body. The respiratory system does
this through breathing. When we breathe, we inhale oxygen
and exhale carbon dioxide. This exchange of gases is the
respiratory system's means of getting oxygen to the blood.
The diaphragm's job is to help pump the carbon dioxide out
of the lungs and pull the oxygen into the lungs. The
diaphragm is a sheet of muscles that lies across the bottom
of the chest cavity. As the diaphragm contracts and relaxes,
breathing takes place. When the diaphragm contracts,
oxygen is pulled into the lungs. When the diaphragm
relaxes, carbon dioxide is pumped out of the lungs [7].
Figure 8. The electronic spirometer [38].
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 Figure 10. Spirostar [29].
Figure 9. The vitalograph [42].

The simple, non-invasive way to measure breath carbon

monoxide levels.

• Hand held, battery operated.

• Easy-to-read display.
• Reliable calibration
• Inexpensive, hygienic operation.
• Excellent for therapy.

Smoking cessation can be a success with the motivation

provided by the BreathCO carbon monoxide monitor. The
BreathCO provides visual proof to the smoker of the
dangerous CO levels in their lungs
Figure 11. SV-3 Spirometer [24].
Showing smokers the poison they are carrying in their
blood and damage they are doing to their bodies as a result The bronchoscope (Figure12)
of their habit is an excellent motivator.
It is an instrument for inspecting the interior of the
The Spirostar DX (Figure 10 and 11) tracheobronchial tree and carrying out endobronchial
diagnostic and therapeutic maneuvers, such as taking
specimens for culture and biopsy and removing foreign
New universal SpiroStar spirometer represents the state of
bodies [33].
the art in dynamic spirometry. It is compact weighting only
22 g. SpiroStar can be connected into a standard (RS-232C)
serial port of a computer. SpiroStar is accurate and precise
and it complies with the ATS spirometry standards (1994)
giving one the assurance of reliable results. Heuristic
system algorithm monitors the stability of the system and
guarantees repeatable and reliable session results.The
application software is Windows (95 / 98 / NT 4.0/ 2000 /
XP) compatible Spiro2000, which provides easy operation,
flexible parameter selection and comprehensive choice of
report formats. One can modify the reports to suite the
requirements. Session results can be transferred into
hospital information systems via local area network or
emailed to consulting physician fast and
faultlessly.Calibration database provides a tool for
professional quality assurance and management system.
SpiroStar includes an automatic temperature sensor to
monitor and correct variations in operating environment.
SpiroStar uses disposable Medikro Flow Transducer, which
provides for better patient safety by eliminating potential
contamination. It increases the system throughput and saves
operating costs. The instrument and the system are
designed to assist one in developing and maintaining a
better and safer lung function testing system for the
patients. Figure 12. Bronchoscope [40].

July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez BB-5
The Incentive Spirometer
Using the incentive spirometer after surgery keeps the
lungs clear. The incentive spirometer also keeps the lungs
active when the patient is recovering from surgery, as if the
patient is at home performing daily activities [20].
How to use the incentive spirometer (Figure 13):
1. Sit on the edge of the bed if possible, or sit up as
far as one can in bed.
2. Hold the incentive spirometer in an upright
position.
3. Place the mouthpiece in the mouth and seal the
lips tightly around it.
4. Breathe in slowly and as deeply as possible,
raising the yellow piston toward the top of the
column. The yellow coach indicator should be in
the blue outlined area.
5. Hold the breath as long as possible (at least for 5
seconds). Allow the piston to fall to the bottom of
the column.
6. Rest for a few seconds and repeat Steps 1 to 5 at
least 10 times every hour when awake.
7. Position the yellow indicator on the left side of
the spirometer to show the best effort. Use the
indicator as a goal to work toward during each
repetition.
8. After each set of ten deep breaths, practice
coughing to be sure the lungs are clear. If the
patient has an incision, support the incision when
coughing by placing a pillow firmly against it.
9. Once the patient is able to get out of bed, walk in
the hallway and cough well, one may stop using
the incentive spirometer unless otherwise
instructed by the health care provider [ 20].
Figure 13. The incentive spirometer [13].
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
This exercise should help the patient [13].
1. Increase in your inhaled lung volume.
2. Improve getting rid of mucus or spit.
3. Avoid serious lung infection.
The Body Plethysmograph
Spirometry is the standard method for measuring most
relative lung volumes; however, it is incapable of providing
information about absolute volumes of air in the lung. Thus
a different approach is required to measure residual
volume, functional residual capacity, and total
lungcapacity. Two of the most common methods of
obtaining information about these volumes are gasdilution
tests and body plethysmography.
In body plethysmography, the patient sits inside an airtight
box, inhales or exhales to a particular volume (usually
FRC), and then a shutter drops across their breathing tube.
The subject makes respiratory efforts against the closed
shutter (this looks, and feels, like panting), causing their
chest volume to expand and decompressing the air in their
lungs. The increase in their chest volume slightly reduces
the box volume (the non-person volume of the box and thus
slightly increases the pressure in the box.
Using the data from the plethysmography requires use of
Boyles Law.
P1V1 = P2V2 /1/
Where: P1 ans V1 are initial pressure and volume, and P2
and V2 are final pressure and volume, measured at constant
temperature.
To compute the original volume of air in the lungs, we first
compute the change in volume of the chest.
We solve for the volume of the box during the respiratory
effort. The difference between this volume and the initial
volume of the box, is the change in volume of the box,
which is the same as the change in volume of the chest.
Armed with this piece of information, we use Boyle's Law
again, this time on the fixed amount of gas in the chest
before and at the end of a respiratoryeffort. We set the
initial volume of the chest (unknown) times the initial
pressure at the mouth (known), equal to the inspiratory
volume of the chest (the same unknown volume plus the
change in the volume of the chest, which we have just
computed) times the pressure at the mouth during the
inspiratory effort (known). Now we solve for the unknown
volume, which will be the original volume of gas present in
the lungs when the shutter was closed. As mentioned
before, the shutter is usually closed at the end of a normal
exhalation, or at FRC.
Body plethysmography is particularly appropriate for
patients who have air spaces within the lung that do not
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communicate with the bronchial tree. In these individules,
gas dilution methods ofmeasurement would give an
erroneously low volume reading [ 12].
The Oxymeter
The pulse Oxymiter allows the continous measurements of
arterial oxygen saturation (%SpO2) as well as the pulse rate
(beats/min.). This non invasive monitor uses a sensor
placed on a finger, toe, or an ear lobe [31].
THE CIRCULATORY SYSTEM
The Circulatory System or cardiovascular system, in
humans, is the combined function of the heart, blood, and
blood vessels to transport oxygen and nutrients to organs
and tissues throughout the body and carry away waste
products. Among its vital functions, the circulatory system
increases the flow of blood to meet increased energy
demands during exercise and regulates body temperature.
In addition, when foreign substances or organisms invade
the body, the circulatory system swiftly conveys disease-
fighting elements of the immune system, such as white
blood cells and antibodies to regions under attack. Also, in
the case of injury or bleeding, the circulatory system sends
clotting cells and proteins to the affected site, which
quickly stop bleeding and promote healing [43].
In order to maintain an adequate flow of blood to all parts
of the body, a certain level of blood pressure is needed.
Blood pressure, for instance, enables a person to rise
quickly from a horizontal position without blood pooling in
the legs, which would cause fainting from deprivation of
blood to the brain. Normal blood pressure is regulated by a
number of factors: the contraction of the heart, the elasticity
of arterial walls, blood volume, and resistance of blood
vessels to the passage of blood [43].
Measurement of blood pressure
Blood pressure is considered a good indicator of the status
of the cardiovascular system, and as one of the
physiological variables that can be quite readily measured.
Blood pressure is measured by means of direct and indirect
methods [43].
Blood pressure is measured at two points: the high point at
which the heart contracts to empty its blood into the
circulation, called systole; and the low point at which the
heart relaxes to fill with blood returned by the circulation,
called diastole. Blood pressure is measured in millimeters
(mm) of mercury by an instrument called a sphygmo
manometer consisting of an inflatable rubber cuff
connected to a pressure-detecting device with a dial. The
cuff is wrapped around the upper arm and inflated by
squeezing a rubber bulb connected to it by a tube. The
sphygmo manometer works on the principle that when the
cuff is placed on the upper arm and inflated, arterial blood
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
can flow past the cuff only when the arterial pressure
exceeds the pressure in the cuff. Also, when the cuff is
inflated to a pressure that only partially occludes the
brachial artery, turbulence is generated in the blood as it
spurts through the tiny arterial opening during each systole.
The Korotkoff sounds that can be heard through a
stethoscope placed over the artery downstream from the
cuff are generated by this turbulence [43].
Blood pressure varies between individuals and even during
the normal course of a day in response to emotion, exertion,
sleep, and other physical and mental changes. The average
normal blood pressure is about 120/80 mm Hg. Higher
blood pressures that are sustained over a long period of
time may indicate hypertension, a damaging circulatory
condition. Lower blood pressures could signal shock from
heart failure, dehydration, internal bleeding, or blood loss
[43].
Blood pressure measurement with a sphygmo manometer
and a stethoscope can be obtained can be obtained by
inflating the pressure cuff, on the upper arm, to a pressure
well above systolic pressure. No sounds can be heard
through the stethoscope that is placed over the brachial
artery, which has been collapsed by the pressure of the cuff.
This pressure is then gradually reduced. Korotkoff sound
can be heard because through the stethoscope because
pressure is below systolic pressure and small amounts of
blood spurts past the cuff. When this fist Korotkoff sound
is heard it is recorded as the systolic blood pressure and is
indicated on the manometer. As the pressure in the cuff
continuous to drop, the Korotkoff sounds continue until the
cuff pressure is no longer sufficient to occlude the vessel
during any part of the cycle. When the Korotkoff sounds
disappear bellow this pressure, the diastolic pressure value
is marked. This method is called the auscultatory method
for locating the systolic and diastolic pressure value [43].
Automatic indirect method
A number of automatic and semiautomatic systems have
been developed. Most devices that utilize a pressure
transducer connected to the sphygmo manometer cuff, a
microphone placed beneath the cuff, and a standard
physiological system on which cuff pressure and korotkoff
sounds are recorded. The procedure is essentially parallel to
the manual method [43].
This instrument is actually semiautomatic because the
recording must still be interpreted by the observer. Fully
automated devices use some type of signal detecting circuit
to determine the occurrence of the first and last korotkof
sounds and retain and display the cuff pressure reading for
these points, either electronically or with mercury
manometer that are cut off by solenoid valves. An example
of automatic blood pressure method is the programmed
electrophyg momanometer PE- 300. This instrument is
designed for use in combination with an occluding cuff,
microphone, or pulse transducer, and a recorder for the
automatic measurements of indirect systolic and diastolic
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blood pressure. The device called electronic sphygmo
manometer incorporates a large gage for easy reading. It is
also called a “semiautomatic,” because the cuff has to be
inflated manually. The microphone and light flash at
systolic pressure detect automatically the Korotkoff sounds
and stops at the diastolic value [43].
Most electronic monitors using arterial cannulae with
electronic transducers and displaysprovide both diagnostic
systolic/ diastolic waveform information and the added
opinion of a single value MAP (mean arterial pressure)
indication. A continuously decreasing or increasing MAP
can ultimately result in a hypertensive or hypontesive
crisis. A simple formula for calculating MAP:
MAP= 1/3 (systolic- diastolic) + diastolic /2/
Mean arterial pressure is a weighted average of systolic and
diastolic pressure. Between the diastolic low and the
systolic peak, MAP falls about one- third of the way.
The mean arterial pressure is determined by the
oscillometric method used in the Dinamap (figure 14). A
solid- state pressure transducer located within the enclosure
senses the pressure pulsations introduced within a cuff
bladder. Pressure oscillations increase in amplitude and
reach a maximum as the cuff pressure is decrease and
passes through the pressure equal to the mean arterial blood
pressure [43].
Figure 14. Dinamap [43].
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
Direct measurements
Methods for direct blood pressure measurements provide a
continuous read out and recoding of the blood pressure
waveform and are considerably more accurate than the
indirect methods. The direct measurement of blood
pressure is usually obtained by one of three methods:
percutaneous insertion, catheterization (vessel cut down) or
implantation of a transducer in a vessel or in the heart [43].
Typically, for percutaneous insertion, a local anesthetic is
injected near the site of invasion. The vessel is occluded
and a hollow needle is inserted at a slight angle toward the
vessel. When the needle is in place, a catheter is fed
through the hollow needle, usually with some sort of a
guide. When the catheter is in place in the vessel, the
needle and the guide are withdrawn [43].
Catheterization
Catheterization has become the major diagnosis technique
for analyzing the heart and other components of the
cardiovascular system. Essentially, a catheter is a long tube
that is introduced into the heart and major vessel by way of
a superficial vein or artery. Measurements of blood
pressure with a catheter can be achieved in two ways. The
first is to introduce a sterile saline solution into the catheter
so that the fluid pressure is transmitted to a transducer
outside the body. In the second method, the transducer is
introduced into the catheter and pushed into the point at
which the pressure is to be measured [43].
Measurements of the heart sounds
The stethoscope is an instrument used for auscultation—
that is, to detect and study sounds arising within organs
such as the heart, lung, and stomach prior to treatment. It is
simply a device that carries sound energy from the chest of
the patient to the ear of the doctor via a column of air. The
stethoscope consists of a bell and diaphragm, or receiving
head, connected by an Y-joint and rubber tubing to two ear
pieces. Since the system is strictly acoustical, there is no
amplification of sound, except for any that might occur
through resonance and other acoustical characteristic. The
sounds may also be amplified electronically. With the
electronic stethoscope, high- fidelity equipment would be
able to reproduce the entire frequency range, of which is
missed by the regular stethoscope [43].
Instruments for graphically recording heart sounds have
been more successful. The phonocardiogram is a graphic
record of the heart sounds. The basic transducer is a
microphone having the necessary frequency response,
generally ranging from bellow 5 Hz to above 100 Hz. An
amplifier with similar response characteristics is required,
which may offer a selective low pass filter to allow the high
frequency cutoff to be adjusted for noise and other
considerations [43].
The presence of higher frequencies or murmurs in the
phonocardiogram indicates a possible heart disorder. A
spectral analysis of heart sounds can provide a useful
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diagnostic tool for discriminating between normal and
abnormal hearts. For this type of analysis it is required a
digital computer with a high- speed analog to- digital
conversion capability and some form of Fourier- transform
software.

Heart sounds are sometimes measured from other vantage

points rather than the chest or over the heart where
microphones and phonocardiograms are designed to be
placed. Special microphone transducers are placed at the
tips of the catheters to pick up heart sound from within the
chambers of the heart or from the major blood vessels near
the heart. The difference in acoustic paths makes these
heart- sound patterns appear somewhat different from the
usual phonocardiogrram patterns as might be expected. The
vibrocardiograph and apex cardiograph, use microphones Figure 15. Cardiac catheterization [43].
as transducers. Since the measurements involve the low
frequency vibrations of the heart against the chest wall, the The blood density increases as the capillaries fill with the
measurement is normally one of the displacements of the amount of light reaching the photocell. The result cause
force rather than the sound. The microphone must be a resistance changes in the photocell that can be measured on
good force transducer with suitable low- frequency a Wheatstone bridge and recorded. Because the photocell
coupling from the chest wall to the microphone element. device cannot be calibrated to reflect absolute or even
The microphone for the apex cardiogram must be coupled relative volumes, pulsations recorded in this manner are
to a point between the ribs. For this purpose, a soft rubber somewhat similar to those obtained by a true
or plastic cone attached to the element of the microphone plethysmograph [43].
gives good results. The volume changes in any part of the
The impedance plethysmograph is more reliable. In this
body are due to the pulsation of blood occurring with each
device, the volume changes in a segment of a limb or digit
heart beat. Such measurements are useful in the diagnosis
are reflected as impedance changes. These impedance
of arterial obstruction as well as for pulse-wave velocity
changes are due primarily to changes in the conductivity of
measurements. Instruments measuring volume changes or
the current path with each pulsation of the blood. The
providing outputs that can be related to them are called
measurements can be made using a two- electrode or a
plethysmographs. Such an instrument consists of a rigid
four- electrode system. The electrodes are either simple
cup or chamber placed over the limb or digit in which the
conductive strips of tape attached to the skin or conductive
volume changes are to be measured. The cup is tightly
bands wrapped around the limb or digit to be measured. In
sealed to the member to be measured so that any changes of
either case, the electrodes contact the skin through a
volume in the limb or digit reflect as pressure changes
suitableelectrolyte jelly or paste to form an electrode
inside the chamber. Either fluid or air can be used to fill the
interface and to remove the effect of skin resistance. In a
chamber.
two-electrode system, a constant current is forced through
the tissue between the two electrodes, and the resulting
Plethysmographs may be designed for constant pressure or
voltage changes are measured. In the four- electrode
constant volume within the chamber. In either case, some
system, the constant current is forced through two outer, or
form of pressure or displacement transducer must be
currents electrodes, and the voltage between the two inner,
including to respond to pressure changes within the
or measurement, electrodes is measured. The internal body
chamber and to provide a signal that can calibrate to
resistance between the electrodes forms the physiological
represent the volume of the limb or digit. Several devices,
divider. The advantage of the four-electrode system is a
called plethysmographs, actually measure some variable
much smaller amount of current through the measuring
related to volume rather than volume itself. One class of
electrodes, thus reducing the possibility of error due to
these “pseudo- plethysmographs” measures changes in
changes in electrode resistance [43].
diameter at certain cross section of a finger, toe, arm, leg,
or other segment of the body. Since volume is related to The reoencephalography is a special form of impedance
diameter, this type of devices is sufficiently accurate for plethysmograph, the measurement of impedance changes
many purposes [43]. between electrodes positioned on the scalp. This technique
provides information related to cerebral blood flow and is
The photoelectric plethysmograph operates on the principle sometimes used to detect circulatory differences between
that volume changes in a limb or digit result in changes in the two sides of the head. Such information might help in
the optical density through and just beneath the skin over a locating blockages in the internal carotid system, which
vascular region. A light source in a opaque chamber supplies blood to the brain [43].
illuminates a small area of the fingerprint or other region to
which the transducer is applied. Light scattered and The oculo pneumo plethysmograph measures every minute
transmitted through the capillaries of the region is picked volume changes that occur in the eye with each arterial
up by the photocell, which is shield from all other light. blood pulsation. A small eye cup is placed over the sclera
of each eye and is connected to a transducer positioned

July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez BB-9
over the patient’s head by a short section of flexible tubing.
A vacuum, which can be varied from zero to –300 mm Hg,
is applied to hold the eye cups in place. Pulsations are
recorded on two channels of a three- channel pen recorder,
one for each eye. The third channel is used to record the
vacuum. By periodically allowing the vacuum to build up
to –300 mm Hg and deplete to zero, the instrument can also
be used as a recording suction ophtalmodynamometer an
instrument for measuring arterial blood pressure within the
eye [43].
Electrocardiography
Electrocardiography (figure 16) is a medical procedure by
which a physician obtains a tracing of the electrical activity
of the heart. The rhythmic beating of the heart is
maintained by an orderly series of discharges originating in
the sinus node of the right atrium and proceeding through
the atrioventricular node and the bundle of neuromuscular
fibers to the ventricles. By attaching electrodes to various
parts of the body, a record of this current can be obtained.
This record is called an electrocardiogram, or ECG for
short. Prominent parts of the ECG are the P wave, a
deflection caused by the current originating in the atrium;
the QRS ( figure 17) complex, showing the passage of the
electrical activity into the ventricles; and the T wave, as the
ventricles reset themselves. The ECG is often helpful in
showing the cause of an abnormal heart rhythm or an
evolving heart attack [43].
An ECG is the graphic display of the electrical impulses
that control muscular contraction and relaxation of the
heart. Monitoring the ECG allows the nurse or doctor to
determine the cause of abnormal cardiac rhythms and
design the appropriate treatment. The ECG is frequently
referred to as an EKG, and one portion of the ECG is
typically continuously monitored in the intensive care unit
[43].
Electrical conduction in the heart is accomplished by a
deceptively simple conduction system. Under normal
conditions, the sinoatrial node is the pacemaker of the
heart, controlling heart rate. The sinoatrial node is
controlled by the autonomic nervous system. Once the
sinoatrial node initiates the electrical impulse, the signal is
carried through a system of conducting fibers known as the
atrial conduction tracts. During passage of this signal, the
atria contract, filling the ventricles with blood. This portion
of the cardiac cycle is the systole. The signal is delivered
to the atrioventricular node, which carries the signal from
the atria to the ventricles. The bundle of His lies just
beyond the atrioventricular node and is responsible for a
slight delay before transmission of the signal to the
ventricles. This delay is generally believed to last
approximately 0.1 seconds and allows the ventricles to
completely fill with blood before contraction. The signal is
then passed through the left and right bundle branches to
the Purkinje fibers and Purkinje network embedded in the
ventricular walls. This coordinated signal results in
uniform contraction of the ventricles and movement of
blood to the pulmonary and systemic circulation [43].
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
Transmission of this signal can be detected by the ECG
electrodes and graphically displayed as the ECG waveform.
The typical waveform is plotted and each major impulse
identified by letters of the alphabet. The distance between
the impulses is also important, and these are known as
segments. The P wave is associated with the initial impulse
of the sinoatrial node. The QRS complex is a depiction of
the ventricular contraction. The QRS signal can appear
differently for a variety of reasons. The first downward
deflection is the Q wave, thefirst upward deflection is the R
wave, and the first negative deflection after the R wave is
known as the S wave. Interestingly, even if the Q wave is
absent, the resulting waveform is still considered a QRS.
The T wave represents relaxation of the ventricles. In some
instances, a U wave may be seen, signaling the final phase
of ventricular relaxation. The distances between these
waves represent the speed of signal conduction, and
intervals and determined for which there are normal values
[43].
The use of 12 leads for an ECG allows the rhythm of the
heart to be examined through different planes. A complete
or 12-lead ECG uses electrodes attached to all four limbs
and six positions on the chest wall. By using these different
attachment points, the ECG can examine the heart rhythm
from a variety of viewpoints, providing a more complete
assessment of cardiac rhythm Quite simply, one lead
provides a one-dimensional view of heart rhythm, and
multiple leads allow a three-dimensional depiction. Leads
are simply electrode pads consisting of a nonconductive
material, adhesive, conducting jelly, and metal connection.
The individual electrodes are placed in the extremities
(usually the wrists and ankles) and at six sites on the chest
wall. The leads are divided into six limb leads and six
chest leads. The six limb leads from four electrodes are
accomplished by varying the signal orientation between the
four extremities. The six chest leads result from the six
electrodes placed on the chest wall [43].
The six limb leads are known as leads I, II, III, aVR, aVL,
and aVF. The first three leads I, II, and III are bipolar leads.
Bipolar refers to the fact that these leads compare the
difference in voltage between any two of the limb leads.
Lead I result from designating the left arm electrode as a
positive electrode and the right arm electrode as a negative
electrode. Lead II results from designating the left leg
electrode as positive and the right arm electrode as
negative. Lead III results from designating the left arm as
negative and the left leg as a positive electrode. The
difference in voltage between the two electrodes is
compared to create the ECG signal. Leads aVR, aVL, and
aVF are known as augmented leads. In each of these cases,
one limb electrode is designated as positive and all others
are designated as negative. The aVR, lead designates the
right arm as the positive electrode, the aVL lead designates
the left arm as the positive electrode, and the aVF lead
designates the left leg as the positive electrode. The term
augmented lead refers to the doubling of the amplification
of the signal required to create the ECG signal in these
leads. Leads I, II, and III are bipolar leads, but the
augmented leads are unipolar leads [43].
BB-10
Figure16. Electrocardiography [43].
The limb leads provide a view of the electrical conduction
of the heart in a frontal plane. That is, the limb leads can
detect electrical activity directed within this plane. The
plane is shown in the form of a circle with the patient’s
head at the top and the patient’s feet at the bottom. The
relationship between the positive and negative electrodes
for each lead (I, II, III, aVR, aVL, and aVF) can be
determined by tracing the angle from the designated
positive and negative sides. This angle is known as the
angle of orientation. As an example, the angle of
orientation for lead I is 0 (straight line from left to right arm
electrode). The angles of orientation of leads II and III are
60 and 90 degrees, respectively. The augmented leads are
somewhat more complicated because three of the leads are
negative. In this case, the average of the three negative
leads is used in comparison with the positive lead. This
provides an angle of orientation for aVR of –150; for aVL of
–30; and for aVF +90. By tracing the angle from one
electrode positive to another, you can see how the ECG Figure17. PQRST waves [43].
machine gets a unique and distinctive view of the electrical
activity of the heart [43].
The chest leads are unipolar leads designated V1’, V2’, “rhythm strips,” which typically display the signal from a
V3’, V4’, V5’, and V6’. These leads are frequently single lead, generally have “tic” marks at the top of the
referred to as the precordial leads and are placed across the paper, outside the grid representing 3 seconds. The vertical
chest in a horizontal plane. The chest leads detect electrical axis uses the same boxes, with the scale being the signal
moving anteriorly or posteriorly (front to back). As such, amplitude. Standard ECG recordings use 10-mm to
the chest leads view the heart through an angle of represent 1 millivolt. The determination of time and
orientation different from that of the limb leads. The voltage is important for detecting abnormalities in heart
positioning of the chest electrodes is important for rate and rhythm [43].
providing the proper use of the heart. When properly Pressure transducer
placed, V1 and V2 are above the right ventricle, V3 and V4
are over the intraventricular septum, and V5 and V6 are This device consists of a catheter, a small open flexible
called lateral leads as a consequence of placement and left tube, filled with a saline solution, and a pressure sensor.
lateral view of the heart. Early ECG technology required One end of the catheter is inserted into the lumen of an
that the operator move the electrode from each chest lead artery and the other end is connected to the pressure sensor.
position to the next to record the chest leads. Today, the The top part of the transducer, known as the dome, is a
six chest electrodes are manufactured in a continuous strip. closed chamber that is connected to the catheter. On one of
The relative position of the electrode is predetermined. The the walls of the chamber is a thin diaphragm that can be
proper positions of these require that the clinician deflected by the force resulting from the difference in
appreciate body size differences among patients and place pressure of the fluid in the chamber and the atmospheric
the electrodes as required [43]. pressure. Strain gauge displacement sensors measure the
deflection of the diaphragm. This deflection is related to the
ECG paper resembles graph paper, with grid like boxes pressure difference with the following equation:
created from horizontal and vertical lines. The lines are
different widths and intensity to allow differentiation of d = [3 *(1 - µ2 )*R4 (∆P)] / (16*E*t3) /3/
time (horizontal) and signal amplitude (vertical). The
individual boxes created by the thin lines are 1 mm2, and Where: d = Displacement of diaphragm center.
the heavy lines are 5 mm2. The horizontal axis of time is µ = Poisson’s ratio.
usually based on a paper speed of 25 mm/sec, although R = Diaphragm radius.
other speeds are commonly available. At this rate, each 1- t = Diaphragm thickness.
mm box represents 0.04 seconds and each 5-mm box E = Young’s modulus for the diaphragm.
represents 0.2 seconds. By simple extrapolation, five of the
∆P = Pressure difference across the diaphragm.
5-mm boxes are equivalent to 1 second. ECG papers, or

July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez BB-11
The diaphragm is connected to four wire strain gauges
located in the transducer. These wires measure the
displacement of the diaphragm. These strain gauges are
arranged in such a way that when the pressure increases
two of the wires elongate while the other two decrease in
length. They are connected as a Wheatstone bridge, which
causes the output voltage to be proportional to the pressure
in the chamber [43].
We have described this device in terms of hydrostatic
pressures. The arterial blood pressure, however, is a time-
varying pressure that follows a complex pattern between
systolic and diastolic pressure over the course of time
between two heartbeats. Accurate reproduction of this
waveform at the pressure transducer entails several
considerations. The fluid in the catheter and the pressure
transducer dome has a mass associated with it. The
catheter, if it is flexible, and the dome and the diaphragm
have an associated compliance. Thus the fluid column and
pressure transducer behave very much as a mass on a
spring. The system is a resonant frequency, which is often
sufficiently low to cause some distortion of the arterial
blood pressure waveform. The system can also generate
artifact in responding to sharp changes in pressure. For
example, a step function in pressure often produces ringing
at the resonant frequency of the system, further distorting
the waveform. It is, therefore, important when using such a
system to consider not only static behavior of the
transducer, but also the dynamic behavior of the
transducer-catheter system [43].
A pressure sensor that does not require the fluid coupling
components eliminates problem associated with the
catheter and pressure transducer dome by miniaturizing the
pressure sensor so that it can be located in the artery at the
site of the pressure measurement. Such a sensor, needless
to say, must be much smaller that the one presented before.
This requires that the diaphragm also is much smaller;
therefore, if unbounded wire strain gauges are used to
measure the diaphragm deflection, the sensitivity is
considerably lower that it would be for the external type of
pressure sensor. Thus, a miniature pressure transducer for
inter-arterial application must employ displacement sensor
with the highest possible sensitivity. The overall sensor is
1.25 by 0.5 by 3.75 mm and occupies a very small volume.
Since the diaphragm is only a fraction of this size, its
deflection will be very small, and this sensor can be
considered to be noncompliant. It will therefore have a very
high resonant frequency that should well outside the
frequency of normal physiological signals from various
biological sources [43].
Ultrasound
Ultrasound is a medical diagnostic technique in which very
high frequency sound is directed into the desired body part.
The tissue interfaces reflect the sound, and a computer
produces a photograph or a moving image on a television
processes the resulting pattern of sound reflection.
Ultrasound can be used to examine many parts of the body,
but its best-known application is the examination of the
fetus during pregnancy. The sound waves used in the
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
ultrasound beam are produced by a rapidly oscillating
crystal, and are inaudible to humans. A device called a
transducer is used to transmit the sound waves and receive
the echoes. The transducer must be in close contact with
the skin, and a jellylike substance is smeared on the skin to
improve the transmission of sound. Ultrasound can be used
to examine the arterial system, heart, pancreas, peritoneal
cavity, urinary system, ovaries, venous system, brain, and
spinal cord. Fluid conducts the sound waves well, making
ultrasound a useful technique for diagnosing cysts (which
are filled with liquid), examining fluid-filled structures
such as the bladder or biliary system, and viewing the fetus
in the amniotic sac. Air, bone, and other calcified tissues
absorb nearly all the ultrasound beam, so this technique
cannot be used to examine the bones or lungs [43].
1. Ultrasound properties: Ultrasound exists as a sequence
of alternate compressions and refractions of a suitable
medium and is propagated through that medium at some
velocity. Its behavior also depends on the frequency of the
sonic energy and the density and mechanical compliance of
the medium through which it travels. The propagation path
for ultrasound into or through the body must not include
bone or any gaseous medium, such as air because almost all
the energy will be reflected and practically none will
continue through the second medium. An airless contact is
usually produced through use of aqueous gel or water bag
between the transducer and the skin consecutively to
applying ultrasound to the body. The density and other
properties of various materials, including several of
biological interest. The temperature and ultrasonic
frequency are given for most of the measurements. The
velocity of sound propagation through a medium varies
with the density of the medium, elastic properties and
temperature. The characteristic impedance of a material is
the product of its density and the velocity of sound through
it. Some energy is absorbed and the wave is attenuated a
certain amount for each centimeter, as ultrasound travels
through the material. The amount of attenuation is a
function of both the frequency of ultrasound and
characteristics of the material. The attenuation constant, α,
is defined by the equation:
α = c*ƒ /4/
Where: α = Attenuation constant.
c = Proportionality constant.
ƒ = Ultrasound frequency.
In equation /4/ with a given amount of ultrasonic energy,
the attenuation increases with some power of the
frequency, which means that the higher the frequency, the
less the distance it can penetrate into the body.
2. Ultrasonic imaging: The invasive imaging of internal
organs of the body is the most widely used applications of
ultrasound in diagnostic medicine. The valuable
information can be provided without the necessity of
surgery or the use of harmful radiation. In general, the
imaging system utilizes the pulsed ultrasound or pulsed
Doppler mode. The received information is displayed in
one of the following display modes after the amplification:
BB-12
a. M- scan display: Here, the received pulse are used to
brighten the trace rather than control the vertical deflection.
Each transmitted pulse triggers the oscilloscope sweep. The
echoes appear as dots with brightness proportional to the
intensity of each echo, this because the brightness level is
set below the visibility threshold. The transducer is held
stationary, thus, the movement of the dots along the sweep
represent movement of the received targets.
b. B- scan display: It presents a two dimensional image of
a stationary organ or body structure. His transducer is
moved with respect to the body while the vertical
deflection of the oscilloscope or movement of the chart
paper is made to correspond to the movement of the
transducer.
c. A- scan display: The simplest form of display. Here,
each transmitted pulse triggers the sweep of an
oscilloscope. The vertical deflections on the trace are that
pulse and the returning echoes displayed. In some cases the
transducer is kept stationary so that any movement of
echoes along the transducer will be the result of moving
targets. The display of an echoencephalogram is an
example of an A- scan [43].
Doppler effect
Doppler is the apparent variation in frequency of any
emitted wave, such as a wave of light or sound, as the
source of the wave approaches or moves away, relative to
an observer. The effect takes its name from the Austrian
physicist Christian Johann Doppler, who first stated the
physical principle in 1842. Doppler's principle explains
why, if a source of sound of a constant pitch is moving
toward an observer, the sound seems higher in pitch,
whereas if the source is moving away it seems lower. An
observer listening to the whistle of an express train from a
station platform or another train can hear this change in
pitch. The lines in the spectrum of a luminous body such as
a star are similarly shifted toward the violet if the distance
between the star and the earth is decreasing and toward the
red if the distance is increasing. By measuring this shift, the
relative motion of the earth and the star can be calculated.
Doppler ultrasound is used to measure the flow of a liquid,
for example blood flow. The amount of frequency shift can
be expressed in the formula:
f = (2*V)/ 8 /5/
Where: f = Shift in frequency of the reflected wave.
V= Velocity of the interface.
8= Wavelength of the transmitter ultrasound.
Ultrasonic Doppler equipment can be employed for
detecting the motion of relatively large structures, such as
heart valves and fetal heart walls. This equipment is also
commonly used for detecting and evaluating the
characteristics of blood flow in arteries and veins. The
sound source or ultrasonic transducer is placed in contact
with the external skin surface and the ultrasound beam is
directed toward the vessel of interest. The sources of echo
signals are the red blood cells following in the vessel. The
Doppler shift is given by the equation:
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
Fd = (fr – f0 )= (2*f0*v) / c /6/
Where: f0 = The initial frequency.
f = The frequency reflected.
v = The velocity.
c = Constant.
Fd = Dopler frequency.
Doppler equipment: The simplest Doppler instruments
use continuous wave and also are the least expensive. In
this, the transmitter continuously excites the ultrasonic
transducer with a sinusoidal electrical signal of frequency.
The transducer converts this electrical energy into
ultrasonic energy, which propagates into the medium. Echo
signals resulting from reflection and scattering return to the
transducer creating an electrical signal that is applied to the
receiver amplifier. Within the amplifier is boosted in
strength and applied to a demodulator and low-pass filter,
with the result that only l0 w-frequency Doppler shift
signals emerge in the output [43].
Pulsed Doppler
Pulsed Doppler provides for discrimination of Doppler
signal from different depths, allowing for the detection of
moving interfaces and scatters only from within a well-
defined sample of volume. The sample volume can be
positioned anywhere along the axis of the ultrasound beam.
The Pulsed Doppler consists of: master oscillator, gated
transmitter, receiver, demodulator and transducer. In such
devices, the ultrasonic transducer is exited with a short-
duration burst from a gated transmitter. Scattered and
reflected echo signals are deflected by the same transducer,
amplified in the receiver, and applied in the demodulator
[43].
The Doppler signal is produced by a pulsed Doppler
instrument is generated from the pulse-to-pulse changes in
phase of the echo signal returning from a target that is
either receding from or moving toward the ultrasonic
transducer. A transmit pulse is emitted by the transducer,
and subsequent echoes are detected from reflectors in the
medium as a single pulse echo sequence [43].
Duplex ultrasound
A pulsed echo scanner and a Doppler instrument provide
complementary information so that the scanner can best
outline anatomic structures, whereas a Doppler instrument
yields information regarding flow and movement patterns.
Duplex ultrasound instrument are real time B-mode scanner
with built-in Doppler capabilities.
In typical applications, the pulse echo B-mode image
obtained with a duplex scanner is used to localize areas
where flow is to be examined using Doppler. Many duplex
instruments allow the operator to indicate the direction of
blood flow with respect to the ultrasound beam. The angle
formed by the ultrasound beam and the flow vector must be
known to estimate flow velocity from the frequency of the
Doppler signal [43].
BB-13
Ultrasonic methods are used in cardiology, in eye analysis,
brain studies, obstetric and gynecology studies. In
cardiology they study ultrasound examination of the heart
known as echocardiography. Echocardiography is used to
study congenital heart diseases, coronary artery diseases,
tumors of the heart and other cardiac disorders. They use a
device that do a studied called echocardiogram, it is the
output obtained by a machine that use essentially duplex to
measure the blood flow, the direction of the flow, the
volume of the flow, and its velocity.
To determine the direction of the flow they colored a
picture in a monitor device according with the reflection of
the ultrasound wave and by a legend they know if the blood
flow is normal or not (see acuson output). Also, they can
use a blind Doppler ultrasound, which is printed in a graph
as a function of the heart beating from where they can
analyze the length of the wave, the amplitude and the
rhythm, to record the heart beating and by they knowledge
determine the patient condition as hypertension or any
other condition [43].
Echocardiology has been extremely useful in diagnosis
many cardiac abnormalities, among them are calcific aortic
stenosis, pulmonary valve stenosis, mitral valve stenosis,
left atrial myxoma, and other heart diseases. In selecting a
transducer for an echocardiography, following factors
should be considered for optimum results:
1. The type of tissue to be encountered.
2. The anatomic area involved.
3. Physical size of the patient.
4. The type of investigation to be performed.
5. The depth of the structure to be studied.
It is possible to distinguish between different soft tissues
and is possible to measure the motion of structures of the
heart with ultrasound techniques. There is no interference
by echoes from other body structures, since the lungs,
which are literally air bags, surround the heart.
The position and movements of each interface of the heart
such as the atrial and ventricular walls, the septum, and
various valves, can be measured by the reflected
ultrasound. The echoes from walls and valves are
predictable since the components of the heart move in a
known manner [43].
Echocardiography is also used in the detection of fluids.
When the pericardium, is inflamed, which is known as
pericarditis, there is sometimes an escape of fluid. The
echocardiogram can detect the presence of this fluid [43].
To prevent blurring of the image due to heart movements
fast scanning speeds are required. Many simultaneous
recordings can be taken in different positions to give a
thorough dynamic analysis, as to give cross-sectional
images at various points along the length of the heart.
The medical profession believes that the potential of this
diagnostic method will continue to increase as the
techniques and interpretations continue to advance [43].
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
Ultrasonic devices
Most of the devices in the ultrasound techniques employ
the same principles. These principles can be Doppler or
Duplex. Some of those devices are:
ACUSON 128XP/10 95’: Uses Doppler to detect the pulse
of the patient in the required area. Also use Duplex to
obtain an image of this area. With a colored scale the
technician can determine the direction of the blood flow,
the speed and his volume.
ADVANCED ACUSON ASPEN: Uses same principle as
ACUSON 128XP, but has more versality. Here, all the
studies (images or videos) can be stored in a memory up to
one month [43].
Echocardiogram
An echocardiogram uses ultrasound, to diagnose a variety
of heart problems. To perform the test a transducer is held
against the chest. The transducer sends ultrasound waves
that reflect (echo) off the various parts of the heart.
A computer processes the information coming from the
transducer to construct an image of the heart. The image is
displayed on a television screen, and it can also be recorded
on videotape or printed on paper [43].
The echocardiogram study usually combines three
different techniques. M-mode echo, produces an image that
looks more like a tracing than an actual heart. The M-mode
echo is especially useful for measuring the exact size of the
heart chambers.
The two dimensional (2D) echo shows the actual shape and
motion of the different heart structures. In a way, the
images represent "slices" of the heart in motion [43].
Doppler echo allows doctors to evaluate the flow of blood
through the heart. The signals representing the flow of
blood are displayed as a series of black and white tracings
or as color images on the television screen [43].
The echocardiogram provides following information about
the heart, such as:
1. The heart chambers and thickness of the heart
muscle.
2. Whether the heart is pumping at full strength or is
weakened. It can also help determine whether the
various parts of the heart pump equally.
3. The shape and motion of the heart valves. It can
help determine if a valve is narrowed or leaking
and show how severe the problem is.
4. Detect the presence of fluid around the heart,
blood clots or masses inside the heart, and
abnormal holes between heart chambers.
5. An echocardiogram is sometimes performed
during or immediately after an exercise test. It
helps doctors determine how well the heart
pumps when it is made to work harder.
BB-14
 DIALYSIS
Dialysis is a process by which free blood toxins and fluid
excess are removed from the blood in the kidney. Two
main methods are used in dialysis: Hemodialysis and
Peritoneal dialysis [43].
The hemodialysis uses a filter to remove toxins and fluids
from the blood. The filter known as dialyzer acts as an
artificial kidney. The amount of blood that circulates at any
time around the artificial kidney is smaller than half liter.
The dialyzer has two compartments by a semi permeable
membrane. Only particles of determined size can cross
through this membrane.
A solution called dialysate circulates to one side of a
membrane and the blood flows through the other side.
Dialysate is composed of water, dextrose (sugar) and
elements similar to the normal fluids of the body without
toxins [43].
In the diffusion process across a semi permeable
membrane, particles of high concentration tends to move to
those of lower concentration until the two solutions reach
equal concentration. In the dialysis, fresh dialysate flows
through the dializer and the waste of the blood turns
towards it until a vast proportion of waste products have
been evacuated from the blood.
placed in the great vein of the neck. This catheter can be
used for the external dialysis during several weeks up to
months [43].
The catheters are covered with clean and dry bandages. The
most common permanent entrances are fistulas and grafts.
A fistula is formed under the skin sewing a vein to an
artery. These increase the amount of blood that flows
through the vein and causes that the vein enlarges [43].
The process by which the fistula acquires the strength and
the size sufficient to allow the insertion of the needle is
denominated as mature. Normally this process entails of
for up to twelve weeks. because the cross- sectional area at
the place of the velocity measurement is well defined with
either type of transducer.
This technique requires that a transducer surrounds an
excised blood vessel, these are mainly used during surgery.
The indicator dilution methods are the only methods of
blood flow measurement that really measure the blood flow
and not the blood velocity [43].
A graft is formed under the skin connecting an artery and a
vein with synthetically material. After surgery intervention,
one may need three to four weeks for the swelling sensation
of the graft to disappear. This graft can be used during the
dialysis [43].

The osmosis is similar to the diffusion, but instead of Peritoneal dialysis

evacuating waste products, evacuates the excess in blood.
The ultra filtration is the process by which pressure is The peritoneal dialysis is based on the same process of
applied in order to eliminate fluid of the blood. The filtration as in the hemodialisys. But instead of using an
pressure on the side of dialysated is applied to extract the artificial kidney as filter, it uses peritoneal membrane.
fluids toward outside.
The peritoneal membrane, also call peritoneum, is a thin
The dialysis personal can regulate the amount of fluids to membrane that covers the abdominal cavity [43].
be extracted during treatment of the dialysis. After a few
hours of dialysis, the blood is relatively purified and the
excessive fluids and waste are removed [43].

Entrance and care: Hemodialysis

In order to make possible that the blood flows from the

body to the dializer and vice versa an ample opening it is
needed to allow a considerable flow of blood. In order to
create this opening, it is necessary to perform a small
surgery, an entrance to the channels of the patient’s blood,
opening which is usually made in an arm or leg [43].

There are several types of entrances: temporally and

permanent. Temporally entrances include the following
types of fistulas (hollow flexible tubes that are partially out
of the body): the intraclavicula, the Femur, and the internal
Jugular. The intraclavicula is a temporally catheter placed
in the intraclavicular vein, exactly underneath the bone of
the neck. It shouldn’t be used during a period of time that
surpasses two weeks [43].

In the Femur the catheter is placed temporally in the great

vein in the ingle. It is only used during the stay of the
patient in the hospital. In the internal Jugular the catheter is Figure 18. Dialysis machine [43].

July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez BB-15
In order to obtain the entrance in the peritoneum, a flexible
sounding or tube is surgically implanted in the low
abdomen. It measures 30.5 cm in length but only 10 or 12
cm of this is outside the body.
The sounding in an operating theater with the help of the
local anesthesia is inserted frequently. During the dialysis
the abdominal cavity with a solution, dialisate fills.
Since the peritoneum is rich in tiny glasses of blood, it
continuously provides a provision with blood that is filtered
by osmosis and diffusion. The flowed excess of toxins in
the blood happens to the dialisate one, which is evacuated
and replaced periodically.
An interchange is the process to evacuate dialisate of the
abdomen and to introduce dialisate fresh in the abdomen.
The time space is known with the name of time of stay that
the dialysis solution remains in the peritoneal cavity during
the peritoneal dialysis (Figure 17).
Measurements of blood flow and cardiac output
The variation in blood supply may be due to of various
diseases. It would be of great help in diagnosing such
diseases by measuring the blood flow in the vessel which
supplies the blood to a particular organ. The blood flow, is
a rather elusive variable that cannot be measured easily
[43].
The rate of flow of a liquid or gas in a pipe is expressed as
the volume of the substance that passes through the vessel
in a given unit of time.
Usually, flow rates are expressed in liters per minute or
millimeters per minute. Almost all blood flow meters
employ following physical principles:
1. Electromagnetic induction.
2. Indicator dilution.
Magnetic blood flow meter
Magnetic blood flow meters measure the mean velocity of
the blood stream. These transducers can be calibrated
directly in units of flow column of conductive fluid that
flows through a tube located in the magnetic field the same
principles applies.
A permanent magnet or electromagnet positioned around
the blood vessel generates a magnetic field perpendicular to
the direction of the blood flow.
The voltage induced in the moving blood column is
measured with stationary electrodes located on opposite
sides of the blood vessel and perpendicular to the direction
of the magnetic field [43].
The slip on or C type is one of the most commonly used
types of implantable magnetic blood flow probes.
Squeezing an excised blood vessel together and slipping it
through the slot of the probe, uses the C type.
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
The orifice of the probe must fit tightly around the vessel
for a proper orientation. The probes can be implanted for
chronic use or during surgery, depending on the model of
the probe [43].
The canula type transducer is a plastic canula around which
the magnet is arranged for blood flow. For this transducer it
is required that the blood vessel be cut and its ends slipped
over the canula and secured with a suture.
A transducer very similar to this one, extracorporeal blood
flow probe is also used to measure blood flow in
extracorporeal devices, such as dialyzers [43].
Magnetic blood flow transducers are also manufactured as
catheter tip transducers. The normal transducer design is
essentially turned “inside out,” with the electromagnetic
being located inside the catheter, which has the electrodes
at the outside.
Since the cross section of the blood vessel at the place of
measurement is not defined, the catheter transducer cannot
be calibrated in flow units [43].
Indicator dilution
Measurement of blood temperature and injection of cool
saline are performed with a specially designed single
catheter. The volume injected of cold saline is normally 10
ml, and the circulating blood is rewarmed rapidly and no
measurable recirculation occurs.
The device used for this technique is called the Swan- Ganz
catheter, which contains four separate lumens.
To inject the cooled saline, is used one of the lumens is
used. The second lumen contains two thin wires whith lead
to a tiny electrical temperature sensor close to the top of the
catheter.
The third lumen ends at the catheter tip and can be used to
measure the blood pressure. To inflate a small rubber
balloon at the tip of the catheter, the fourth lumen of the
catheter itself is used. The balloon is inflated and the
returning venous blood carries the catheter until its tip is
positioned in the pulmonary artery once the catheter has
been inserted into the vein [43].
The thermistor, which is an electronic temperature- sensing
device, is connected into a bridge circuit for measuring and
recording blood temperature during injection. The analog
computer that consists of electronic integrator and
necessary controls makes possible the reading of the
cardiac output directly [43].
Noninvasive blood glucose monitoring
Noninvasive blood glucose monitoring involves either
folowing promising technologies:
1. Near Infrared light (NIR) spectroscopy
2. Far Infrared Radiation (FIR) spectroscopy
BB-16
 3. Radio Wave Impedance
4. Optical Rotation of Polarized Light
5. Fluid extraction from skin
6. Interstitial fluid harvesting.
Near infrared radiation (NIR) spectroscopy
The term NIR refers to the use of an external light source
with wavelengths in the infrared spectrum near the
wavelengths of visible light.
An NIR source can pass through or be reflected by a body
part. Glucose and other body constituents absorb a small
amount of the light at each wavelength [43].
Spectroscopy, an established technology used to measure
energy containing many wavelengths, detects the amount of
NIR absorbed at each wavelength by comparing a reference
Figure 19. Peritoneal Dialysis [43].
beam with the detection beam that has passed through or is
reflected by the body.
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
With spectroscopy, light absorption at selected wavelengths
is analyzed for each blood glucose level. A polynomial
formula is generated converting the sum of the relative
contributions of absorption at the selected wavelengths to
the blood glucose concentration. This technology is used in
oximetry to measure the oxygen saturation of blood [43].
The major problem with using NIR spectroscopy for blood
glucose monitoring requires frequent recalibration under
following situations :
1. Use of medications that absorb NIR.
2. Alterations in the blood hemoglobin level, body
temperature, or state of hydration.
Far infrared radiation (FIR) spectroscopy
Thee FIR spectroscopy measures absorption of far infrared
radiation contained in natural thermal emissions or body
heat. FIR it does not require an external energy source
[43].
The term thermal emissions refers to deep layers of the
human body emitting thermal radiation or body heat with
wavelengths in the far infrared radiation spectrum far from
the wavelengths of visible light. When FIR passes out of
the body, glucose in the blood absorbs part of the radiation
[43].
Thermal energy absorption of FIR by blood glucose can be
spectroscopically determined by comparing measured and
predicted amounts of thermal energy at the skin surface.
The predicted amount of thermal energy radiated can be
calculated by the Planck distribution function.
Simultaneous measurement of thermal energy absorption
outside the FIR "glucose band" determines the reference
intensity that is a necessary variable for calculating the
blood glucose concentration. The percentage of thermal
energy absorption can be arithmetically converted to a
blood glucose concentration. This technology is used in
tympanic thermometry to measure body temperature [43].
FIR spectroscopy for blood glucose monitoring has two
problems: First, the signal size of human thermal emissions
is very small. Second, the prototype device incorporates
cryogenically cooled infrared detectors. Replenishment of
the cryogenic fluid, currently liquid nitrogen, is
inconvenient [43].
Radio wave impedance
Radio wave impedance technology for blood glucose
monitoring also faces two problems: first, impedance is
also affected by factors other than glucose, which must be
accounted for to determine the relationship between
impedance and blood glucose concentration. These factors
include the concentration of electrolytes in the blood, finger
width, and body temperature. Second, an inexpensive
disposable finger clip may be necessary to conduct the
radio waves [43].
BB-17

Figure 20. Sensitiving glucose sensing [43]
Optical rotation of polarized light
The polarimetry is a optical rotation of polarized light.
When polarized light passes through a fluid that contains
glucose, the plane of polarization rotates proportionate to
the glucose concentration. A beam of infrared polarized
light can be used to pass through a body compartment, and
the amount of optical rotation can then be measured [43].
In polarimetry, a beam splitter divides a polarized light
beam into a reference beam and a detection beam, which
passes through the body. The beams are then compared to
determine the amount of phase shift produced by passage
through the body. A blood glucose level is calculated by
applying a conversion factor to the phase shift. This
technology is used industrially to measure the
concentration of sugar in foods and dextrose in intravenous
solutions [43].
Fluid extraction from skin
This technology extracts and measures tissue fluid from
skin. Also known as reverse iontophoresis, this method is
accurate and produces multiple measurements over a 24-
hour period. A device using this technology will measure
trends in blood glucose concentrations and will be
programmed to control an insulin delivery system that will
create an artificial pancreas. Fluid extraction from skin is
the only noninvasive blood glucose monitoring technology
capable of measuring blood glucose levels continuously
without patient effort [43].
Reverse iontophoresis involves application of an electrical
current to the skin followed by extraction of fluid. The
current pulls out salt, which carries water, which in turn
carries glucose. The glucose concentration of this extracted
fluid can be measured and is proportionate to that of blood.
Iontophoresis, from which reverse iontophoresis derives, is
an effective drug delivery technology [43].
A noninvasive blood glucose monitoring system that will
resemble a wristwatch is being developed. This system,
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
called the GlucoWatch, will extract fluid from the skin
using reverse iontophoresis. A blood glucose level could be
reported as often as three times per hour. A programmable
alarm will sound if high or low panic values are exceeded
[43].
Interstitial fluid harvesting
This technology involves transcutaneous harvesting and
measurement of interstitial fluid from skin.
While the aforementioned technologies produce neither
skin trauma nor pain, transcutaneous harvesting of
interstitial fluid can be accomplished with nearly no skin
trauma and minimal sensation. Therefore, this technology
is classified not as "noninvasive," but rather as "nearly
noninvasive [43].
Transcutaneous harvesting of interstitial fluid produces no
significant breaks in the skin surface, in contrast to
"minimally invasive" technology, which involves inserting
an indwelling subcutaneous glucose sensor. Transcutaneous
interstitial fluid harvesting technology is so similar to the
noninvasive technologies that this "nearly noninvasive"
technology is included in this discussion of noninvasive
monitoring [43].
Collecting interstitial fluid is less inconvenient than
collecting blood in terms of:
1. Pain
2. Skin trauma
3. Site restriction (sampling is not limited to the
fingertips), and risk of contamination
Interstitial fluid harvesting involves extraction of fluid from
the skin includes the following methods:
1. Penetration with a 29-gauge needle
2. Disruption with chemicals, and
3. Microporation with a laser.
The concentration of interstitial fluid glucose has been
shown to be equivalent to that of serum glucose when the
serum glucose level is stable. Recent studies have also
demonstrated such equivalence when the serum glucose
level is rapidly rising or falling. The finding that dermal
interstitial glucose is an indicator of ambient glycemia
helps validate the proposed substitution of interstitial fluid
for blood as an accurate measurement of diabetic control
[43].
HUMAN REPRODUCTIVE SYSTEM
Ultrasound
Ultrasound is a scan used to study internal body structures.
It works by sending out high frequency sound waves,
directed at the internal body part being examined,
andrecording the reflected sound or 'echoes' to create an
image.
BB-18

Figure 21. Sperm Count Test [30].
The sound waves are emitted from a small, vibrating crystal
in a hand-held scanner. The high frequency of the sound
means it can't be heard by the human ear. An ultrasound
scan doesn't produce high quality images, but it is non-
invasive and doesn't involve radiation. It is commonly used
to study the abdominal organs, pelvic organs and breast
tissue. Other names for ultrasound scan include sonogram
and ultrasonography [6].
Pregnancy scan is used to check for fetal abnormalities
(such as spinal bifida), check the age and sex of the fetus,
and monitor fetal growth and development. An ultrasound
scan during pregnancy may need to be performed every
three months (each trimester), according to the doctor's
recommendations.
Sperm count
It is number of sperms in an ejaculate. The sperm count is a
indicator of male fertility. The test can look at many
aspects of sperm production and release. In 1 in 20 samples
no sperm at all are seen. This is due to either obstruction or
a failure of production. Although, in theory, only 1 sperm is
needed to conceive, there is a direct relationship between
the number of sperm and the chances of pregnancy. The
cycle of sperm production in the testis takes about 70 days
so the test shouldn't be repeated too close as it takes a while
for the cycle to recover [6].
Rigid Scan
The Rigid Scan. is a pressure device that consists of a
collector for data and two rings. The patient should put the
rings in the upper and lower part of his penis. The scan will
read the blood pressure of the patient during the night and
the ring will contract or expand depending on the penis
activity during the night. This helps the specialist to
determine: If the circulation in the penis is a normal one or
if the patient is impotent [6].
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
HUMAN DIGESTIVE SYSTEM
Digestion includes mechanical and chemical processes. The
mechanical processes include chewing to reduce food to
small particles, the churning action of the stomach and
intestinal peristaltic action. These forces move the food
through the digestive tract and mix it with various
secretions. Three chemical reactions take place in this
process: conversion of carbohydrates into such simple
sugars as glucose, breaking down of protein into such
amino acids as alanine, and conversion of fats into fatty
acid and glycerol. Specific enzymes accomplish these
processes [9].
When food is chewed and swallowed the six salivary
glands produce secretions that are mixed with the food. The
saliva breaks down starches into dextrin and maltose,
dissolves solid food to make it susceptible to the action of
later intestinal secretions, stimulates secretion of digestive
enzymes, and lubricates the mouth and esophagus for the
passage of solids [9].
The digestive system is responsible for the digestion,
absorption, and assimilation of fluids, macro- and micro-
nutrients (vitamins and minerals) and the elimination of
waste from the gastrointestinal tract. Food and drink that
we ingest is broken down by our digestive system into
smaller simple particles (molecules) before it is absorbed
by the small intestine and transported into the blood stream
that carries the nutrients, vitamins, and minerals to cells
throughout the body. In the cells the molecules provide
energy and nourishment to the body [9].
Colonoscopy
The term "colonoscopy" means looking inside the colon. It
is a procedure performed by a gastroenterologist.The
colonoscopy (figure 21) is used to look inside the colon.It
is a long, thin, flexible tube with a tiny video camera and a
light on the end. By adjusting the various controls on the
colonoscope, the gastroenterologist can carefully guide the
instrument in any direction to look at the inside of the
colon. The high quality picture from the colonoscope is
shown on a TV monitor, and gives a clear, detailed view.
Colonoscopy is more precise than an X-ray. This procedure
also allows other instruments to be passed through the
colonoscope. These may be used to remove a suspicious-
looking growth or to take a biopsy.A shorter version of the
colonoscope is called a sigmoidoscope, which is used to
screen the lower part of the large bowel only [9].
Colonoscopy can also check colon cancer and treat colon
polyps-abnormal growths on the inside lining of the
intestine. The colonoscopy process includes:
1. The colonocscope is inserted in the anus and
gently guided to the cecum, the first part of your
digestive tract.
2. Upon reaching the colon, the specialist can guide
the colonoscope to view the entire area.
3. Upon finding something suspicious, the specialist
can take a biopsy.
BB-19
 Endoscopic Retrograde Cholangio Pancreatography
(ERCP)

Retrograde refers to the direction in which the endoscope is

used to inject a liquid enabling X-rays to be taken of the
parts of the GI tract called the bile duct system and
pancreas. Cholangio refers to the bile duct system and
pancreas. The process of taking these X-rays is known as
cholangiopancreatography. ERCP may be useful in
diagnosing and treating problems causing jaundice (a
yellowing of the whites of the eyes) or pain in the
abdomen.

Other special exams that take pictures using X-rays or

sound waves may provide complement important
information from ERCP. The ERCP process includes:

1. The gastroeneterologist may determine that a

Figure 22. Colonoscopy [43].
Upper GI Endoscopy
The term "endoscopy" refers to a special technique for
looking inside a part of the body. "Upper GI" is the portion
of the gastrointestinal tract, the digestive system, which
includes the esophagus, the swallowing tube leading to the
stomach [9].
stone is blocking a common duct.
1. 2. An endoscope will be lowered down the
esophagus, through the stomach, and into the
duodenum. A small tube will be threaded down
into the duct.
2. A dye will be injected backwards through the
ducts, allowing X-rays to be taken.
3. The specialist will be able to remove the stone
that is blocking the duct with the endoscope.

Upper GI endoscopy (figure 24) is a procedure performed

by a gastroenterologist, who uses the endoscope to
diagnose and, in some cases, treat problems of the upper
digestive system. The endoscope (figure 54) is a long, thin,
flexible tube with a tiny video camera and light on the end.
By adjusting the various controls on the endoscope, the
gastroenterologist can safely guide the instrument to
carefully examine the inside lining of the upper digestive
system.The high quality picture from the endoscope is
shown on a TV monitor; it gives a clear, detailed view. In 1 2
many cases, upper GI endoscopy is a more precise
examination than X-ray studies.

Upper GI endoscopy can be helpful in the evaluation or

diagnosis of various problems: difficulty in swallowing,
pain in the stomach or abdomen, and bleeding, ulcers, and
tumors.

1. The endoscopy process

1. The endoscopy is inserted in the mouth and

gently edged down the esophagus.
2. The endoscope will be inserted until it reaches
the stomach.
3. Once in the stomach, the specialist will look 3 4
closely for any problem areas. Figure 23. Sequence of a colonoscopy [43].
4. If anything suspicious is found, the doctor will
take a sample for biopsy.

July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez BB-20
 DIGESTIVE SYSTEM TESTS

Cholangiography (Intravenous)

Intravenous cholangiography is a contrast x-ray used to

detect gallstones, obstructions, or other abnormalities of the
gallbladder and bile ducts. The same procedure may be
done using a CT scan rather than conventional x-ray [43].

The patient will have a high-fat meal the evening before the
test, followed by nothing but water or fat-free liquids. A
laxative may be given, since a full bowel can create
shadows on the x-ray [43].

The test usually lasts about 2 to 2 1/2 hours, if the bile

ducts are not obstructed. If they are, it may take 4 to 24
hours for the contrast medium to concentrate in the
gallbladder [43].

The test is done in a hospital. After preliminary x-rays are

taken with the patient lying down on a tilting x-ray table,
the contrast medium is administered intravenously and
more pictures are taken at different angles [43].

The only risk is possible allergic reaction to the contrast

medium. To help minimize this, a small amount is
administered first and reaction checked before the full dose
is given. There may, however, be side effects including
nausea, vomiting, hives, or flushing [43].

Cholangiography (Percutaneous Transhepatic)

Figure 24. Endoscope [43].
This is a contrast x-ray study of the bile duct, often used to
diagnose causes of jaundice. It is especially useful with
patients who have had their gallbladders removed. No food
is given for about 8 hours before the test [43].

This procedure lasts about 30 minutes. It always performed

in the hospital. The patient lies on a tilting x-ray table and a
local anesthetic is injected into the skin covering the liver
and the capsule surrounding it. A long, flexible needle
guided by a fluoro-scope is inserted into the liver in an
attempt to find a dilated bile duct, and the contrast medium
administered through it. Then a series of x-rays is taken as
the table is rotated to different angles [43].

A number of complications can result from this procedure,

including bleeding, septicemia (a bacterial infection of the
blood), and bile peritonitis caused by bile leaking from the
punctured duct, but these are rare. Although the radiation
exposure from a single cholangiography is small, there is a
risk if the procedure is repeated several times. The patient
will feel some sting from the needle used for the anesthetic,
but will not feel the needle being inserted into the liver.
When the dye is injected, there may be a feeling of fullness
or pressure. Side effects of the contrast dye sometimes
include nausea, vomiting, excessive salivation, hives, and
sweating [43].

Cholecystography

Figure 25. Upper GI [43]. Cholecystography is a contrast x- ray study of the

July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez BB-21
gallbladder used to detect gallstones or to diagnose
inflammatory disease and tumors. At noon on the day
before the test, the patient eats a meal that contains normal
amounts of fat, which stimulates release of bile from the
gallbladder, emptying it of normal bile and preparing it to
accept bile containing a contrast medium. This is followed
by a fat-free dinner, which causes the contrast-containing
bile to collect in the gallbladder. After dinner, at 5-minute
intervals, the patient takes a series of pills containing the
contrast dye. The test takes about 30 to 45 minutes. This
outpatient procedure is simply a series of x-ray pictures
taken with the patient in different positions. After the initial
pictures, the patient may be given a high-fat meal or a pill
to produce the same effect, and asked to wait 15 to 20
minutes, after which another set of pictures is taken [43].
Except for possible allergic reaction to the contrast
medium, there is no risk involved in this test. Some people
suffer temporary side effects caused by the pills, most
commonly diarrhea and occasionally nausea, vomiting, or
difficulty in urinating [43].
Colonoscopy
Colonoscopy is the direct examination of the large intestine
using a flexible fiber-optic tube inserted through the anus.
It is used to detect inflammatory or ulcerative bowel
disease, to check for polyps or tumors, or to locate the site
of gastrointestinal bleeding [43].
The patient is given a liquid diet for 1 to 2 days before the
exam, followed by a laxative and one or more enemas to
completely empty the bowels. A sedative or tranquilizer
may also be given [43].
This procedure takes 30 to 60 minutes. It can be done as an
outpatient procedure, but is usually done in the hospital.
With the patient lying on his or her side and knees flexed, a
colonoscope is passed through the intestine. Air may be
injected to expand the folds of the colon, enabling the
doctor to see the entire surface area. When the tube has
reached the entire length of the colon, it is slowly
withdrawn as the doctor examines the lining for any lesions
or polyps. Special attachments allow the removal of some
small polyps or the collection of a biopsy sample [43].
There is very little risk of bowel perforation, but the patient
should report any bleeding, dark stool, or abdominal pain.
Many patients feel embarrassment and discomfort during
this procedure, especially when air is injected and expelled
[43].
Duodenography
Duodenography (also called hypotonic duodenography)
provides x-ray pictures of the duodenum and the pancreas
and is used to diagnose tumors or lesions that may be
causes of upper abdominal pain. The patient must fast for 6
to 12 hours before the test [43].
This test takes about 30 minutes. It can be done on an
inpatient or outpatient basis. The patient is seated, and a
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
long, flexible tube called a catheter is passed through the
nose into the stomach. The patient then lies down and the
doctor, guided by a fluoroscope screen, continues to pass
the catheter into the duodenum. Injection or IV gives a
hormone or drug to relax the duodenum, and then the
contrast medium is administered through the catheter and
x-rays are taken from a number of angles. Some of the
barium is then withdrawn and air injected through the
catheter, which may cause the patient to have cramps. More
x-rays are taken before the catheter is removed [43].
Risks, which include allergy to the contrast medium or
possible internal damage from the introduction of the
catheter, are rare. More common are side effects such:
nausea, vomiting, hives, flushing, blurred vision, dry
mouth, thirst, irregular heart rhythms [43].
Endoscopy
Endoscopy is a diagnostic test that enables the doctor to
look inside the upper digestive system. The instrument used
to perform this simple test is the endoscope, a long thin
flexible tube that has at one end a miniaturized color TV
camera with a wide angle lens. By passing this "scope" into
your stomach, the doctor can directly examine the lining of
the upper digestive system on a television monitor. The
technical name for this test is Esophago-Gastro-
Duodenoscopy. To simplify things the shortened form of
the name endoscopy is usually used, or the initials EGD.
The examination is quick and painless. There is no incision
[43].
Alternate testing
As part of the evaluation, the doctor may have already
ordered a barium x-ray of upper digestive system. This x-
ray exam may have been helpful in directing attention to an
area of possible abnormality. But x-rays often do not fully
reveal all [43].
Fortunately, endoscopy permits a much more accurate view
of the upper digestive system. Rather than studying an
indirect x-ray "shadow picture" of the stomach, endoscopy
allows the doctor to directly view the upper digestive tract
in "living color" and to examine the lining in remarkable
detail. Thus, it is much more accurate [43].
Understandably, most patients are a bit apprehensive about
the idea of "swallowing a scope." However, with the help
of modern medical instruments and sedation, patients
usually tolerate this test with relative ease. Endoscopy is
useful in diagnosing the following:
1 Abdominal pain.
2. Bleeding from the digestive tract.
3. Cancers of the stomach or esophagus.
4. Chronic heartburn and indigestion.
5. Detection and treatment of esophageal varices.
6. Diagnosis and removal of stomach polyps.
7. Dilatation of esophageal strictures.
8. Gastritis, or stomach inflammation.
9. Hiatal hernia.
BB-22
 10. Removal of swallowed objects.
11. Trouble swallowing.
12. Treatment of the "Ulcer Bacteria".
13. Ulcers of the esophagus.
14. Ulcers of the stomach u Ulcers of the duodenum.
15. Unexplained chest pain.
Endoscopy Retrograde Cholangiopancreatography
(ERCP)
ERCP is x-ray visualization of the ducts leading from the
pancreas and the gallbladder is used to diagnose the
presence of stones or tumors in these ducts.
The patient is asked to fast for 12 hours before the test and
is usually given a sedative or tranquilizer. Local anesthetics
(generally unpleasant tasting) is used in either spray or
gargle form to suppress gagging, and it causes the patient to
lose some control of saliva. A mouth guard may be inserted
to protect the teeth [43].
ERCP takes about 60 minutes. While it can be done on an
outpatient basis, it is usually done on an inpatient basis.
The endoscope is inserted into the mouth and down the
throat and the patient is instructed to swallow to help pass it
down into the esophagus. Guided by a fluoroscope, the
doctor then continues to pass it down into the stomach and
duodenum, and then injects a drug into the duodenum to
relax it. Next the contrast medium is injected through the
endoscope and a series of x-rays is taken. Another set may
be taken in different positions after the scope is removed.
The patient may feel side effects from the drug or hormone
used to relax the duodenum and from the contrast medium.
These include nausea, hives, blurred vision, dry mouth,
urinary retention, and a feeling of burning or flushing. The
throat may be sore for 3 or 4 days afterward [43].
Besides the slight risk of infection or perforation of internal
organs that accompanies any invasive procedure, there is
also the problem of urine retention, especially in men with
prostate problems. This can usually be avoided by voiding
completely before the exam.
Esophagography
Although this test is occasionally done alone, when the
doctor is reasonably sure that the problem is confined to the
esophagus, it is usually done as part of the upper GI series.
Gastric secretion studies
This procedure allows the physician to collect and study
samples of the gastric juices secreted by the stomach to
diagnose causes of epigastric pain or learn more about
suspected ulcers before surgery. The patient is usually fed a
liquid meal and then asked to fast for 12 hours and to
restrict liquids and smoking for 8 hours prior to the test.
Part of the test may involve eating, drinking, or chewing to
stimulate production of gastric juices. [43]
Although the secretions are all collected in the same
manner, the test can last anywhere from 2 to 12 hours,
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
depending on the objective of the test. The longer test
requires hospitalization, but the shorter ones may be done
on an outpatient basis. The doctor passes a long, flexible
tube through a nostril down the patient's throat into the
stomach. Once the tube has been started, the patient is
asked to swallow until the tube enters the stomach. The
gastric juices are then aspirated and collected through the
tube over a period of hours [43].
The test is uncomfortable and may cause gagging when the
tube is initially passed and some irritation in the nostril or
throat afterward. Other risks, which are rare, include lung
collapse or ulceration of the larynx if the tube is passed into
the trachea instead of the esophagus [43].
Gastroscopy
Gastroscopy (also called esophagogastroduo-denoscopy)
allows a direct view of the lining of the esophagus,
stomach, and duodenum through an endoscopic tube. It is
used to determine the cause of bleeding to perform a
biopsy, or to diagnose inflammatory disease, tumors,
ulcers, and structural abnormalities [43].
The patient is asked to fast for 6 to 12 hours beforehand
and is given a sedative or tranquilizer. A local anesthetic is
sprayed into the mouth and throat. The procedure takes
about 30 minutes. It may be done on an inpatient or
outpatient basis. A flexible fiber-optic tube is passed
through the mouth down the esophagus and into the
stomach and duodenum [43].
The tube, which transmits light and allows the doctor to see
the internal structure of various organs, also has
attachments that allow the suctioning off of secretions,
taking of biopsy samples, and introduction of air, which
expands the organs and makes examination easier. As with
all invasive procedures, there is some risk of internal
damage to organs or structures, such as perforation, but this
is relatively rare. The patient may feel some gagging,
cramps, or fullness as the tube is passed through various
organs or when air is introduced, and will probably have a
sore throat afterward [43].
Liver scan
This isotope study provides information on the structure
and functioning of the liver and is used to detect cirrhosis,
abscesses, or growths. There is no risk, other than the
remote possibility of isotope overdose. No special
preparation is necessary. The procedure takes about 45 to
60 minutes for a structure scan and 30 minutes for each
function scan, which are done in a series with the final one
after 24 hours. The procedure may be done on an
outpatient basis. The isotope is injected and a blocking
agent may be used [43].
Lower GI Series
Like the upper GI Series, this x-ray exam (also called
barium enema) uses barium as a contrast medium to
provide fluoroscopic views, in this case of the large
BB-23
intestine. The procedure is used to detect polyps, tumors,
gastroenteritis, telescopic bowel, irritable colon or other
causes of lower abdominal pain, or blood, mucus, or pus in
the stool [43].
Before the examination, the patient may be asked to fast or
go on a liquid diet, and then laxatives or one or more
enemas will be used to empty the bowels.
The test takes 30 to 45 minutes. It can be done in a doctor's
office, testing facility, or hospital outpatient clinic. The
barium enema is administered through a tube inserted into
the rectum while the patient lies on his side on a tilting x-
ray table. The table will be rotated to allow the barium to
completely coat the large intestine and x-ray pictures will
be taken. The patient will then be helped to a bathroom or
given a bedpan and told to expel as much of the barium as
possible. More pictures will then be taken of the thin film
that remains on the mucous lining of the intestine. In some
cases, this will be followed by a double contrast study,
meaning air will be carefully injected into the colon to
provide further contrast on the film in order to detect
possible polyps [43].
Although this procedure is unpleasant and often
uncomfortable, there are no serious complications. Risks,
such as perforation of the bowel, are rare. The procedure
causes some discomfort, including a strong urge to defecate
and mild or, especially with the air contrast study,
moderates to severe cramps. The stool will be white or light
colored for a few days following the test, and the barium
may be constipating. For this reason, the test is sometimes
followed by a laxative or another enema [43].
Pancreas Scan
This radioisotope scan provides information on the
structure and functioning of the pancreas to help detect
cancer, cysts, or infection. There is a rare risk of
radioisotope overdose.
Figure 26. Gastroscope [43].
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
The patient follows a high-protein diet for several days
before the test, then fasts for 8 to 12 hours, with the
exception of a glass of skim milk a few hours before the
test. Another high-protein liquid is given at the time of the
test.
A pancreas scan takes 1 to 2 hours. It may be done on an
inpatient or outpatient basis. The isotope sometimes causes
nausea or vomiting [43].
Proctosigmoidiscopy
A proctoscope exam (also called proctoscopy) allows the
doctor to see the rectum and the lower part of the large
intestine. It may be used to detect hemorrhoids, polyps, and
abscesses or to determine the cause of bleeding. It is
routinely used to screen for cancer after age 40, even if
there are no symptoms [43].
The patient may be instructed to have a liquid diet or to fast
for a few hours, followed by an enema or suppository.
This procedure takes 10 to 20 minutes. It may be carried
out in a doctor's office or in a clinic. With the patient in the
knee-chest position, the doctor will do a digital rectal exam,
using a gloved finger, and then insert the proctoscope,
which may be a rigid or a flexible tube. The procedure is
similar to the colonoscopy, but not as extensive [43].
Although the patient may feel some irritation around the
anus afterward, this is a routine, safe procedure, with the
risk of injury to the large intestine being very rare. The
patient may feel some discomfort and the urge to defecate
during the procedure [43].
Sialography
This procedure (also called ptyalography) allows x-ray
visualization of the salivary glands to diagnose stones in
the salivary ducts or other causes of an enlarged or painful
salivary gland [43].
No special preparation is required, except possibly fasting
for a few hours beforehand. The patient may be given a
sedative. This procedure takes about 45 to 60 minutes. It is
usually performed on an outpatient basis. A catheter is
inserted through the mouth into the duct of the salivary
gland to be studied and a contrast medium is injected
through the catheter. The doctor examines the gland using a
fluoroscope and may take x-rays. There is some discomfort
when the catheter is inserted and pain when the dye reaches
the salivary gland [43].
As with all invasive procedures, there is a rare risk of
internal damage or infection. The patient will continue to
taste the contrast dye and experience some soreness in the
mouth after the procedure [43].
Small Bowel Examination
This exam is usually done in conjunction with an upper GI
series. This fluoroscopic examination (also called barium
milk shake or barium swallow) of the esophagus, stomach,
BB-24
and small intestine is used to diagnose cases of hiatal Measurements for the nervous system
hernia, ulcers, tumors, obstruction, or enteritis, and when
there are symptoms such as difficulty in swallowing,
regurgitation, burning or gnawing abdominal pain, We can measure direct electrical activity of the nervous
diarrhea, weight loss, or bleeding [43]. system by many ways. The effects of the nervous system
on the other system of the body are manifested in most
The patient may be asked to eat a low-residue diet for 2 or physiological measurements. The Gate Control Theory
3 days before the test and will be asked not to eat or smoke suggests that by electrically stimulating sensory nerve
for 6 to 12 hours prior to the exam. receptors, a gate mechanism is closed in a segment of the
spinal cord, preventing pain-carrying messages from
It may take anywhere from 30 minutes (for just the reaching the brain and blocking the perception of pain. We
esophagus) to 60 minutes (for the esophagus and stomach) can stimulate sensor neurons with the specific type of
to 6 or more hours (if the small intestine is also included). stimulus and measure the responses in various nerves, in
This test may be done in a testing facility or in a hospital on some cases, in individual neurons either in the peripheral or
an inpatient or outpatient basis. It begins with the patient central nervous system measurement. The Endorphin
swallowing a "barium milk shake," a sweetened, flavored, Release Theory suggests that electrical impulses stimulate
but nonetheless chalky-tasting substance containing barium the production of endorphins and enkaphalins in the body.
sulfate, a contrast medium that outlines the upper digestive These natural, morphine-like substances block pain
tract. Sometimes a more liquid radiopaque material is used. messages from reaching the brain [15].
The patient is strapped securely to a tilting x-ray table, Open MRI equipment
which starts in a vertical position with the patient standing,
and is tilted at various angles throughout the test to help The MRI is a medical diagnostic technique that creates
spread the contrast medium and to get different views on images of the body using the principle of nuclear magnetic
the fluoroscope. Pressure may be applied to the patient's resonance. This machine can generate images of thin
abdomen to spread the medium further. If the test is to sections of any part of the body, including the heart,
include a small bowel exam, the patient will have to wait arteries and veins from any angle and direction, in a
several hours until the barium filters down into the relative short period of time.
intestine, and may be able to leave and come back, or to MRI is possible in the human body because the body is
spend the time reading [43]. filled with small biological magnets, the most abundant and
responsive of which the proton, the nucleus of the hydrogen
Although the barium is unpleasant tasting and will make atom. The MRI stimulates the body with ratio waves to
the patient's stool white for several days (unless a laxative change the steady-state orientation of protons. It then stops
is given to speed its passing), there is no pain, little the ratio waves and listens to the body’s electromagnetic
discomfort, and virtually no risk with this test, unless it is transmissions at a select frequency. The transmitted signal
repeated several times, when radiation then becomes a risk is used to construct internal images of the body. MRI is
[43]. preferred for diagnosing most diseases of the brain and the
central nervous system. It can distinguish soft tissue in both
THE NERVOUS SYSTEM normal and diseased states [15].
The nervous system of the human being is responsible for
sending, receiving, and processing nerve impulses
throughout the body. All the organs and muscles inside our
body rely upon these nerve impulses to function. It could
be considered as the master control unit inside the body.
Sense organs provide the nervous system with information
about the environment by means of such senses as sight,
hearing, smell, taste, tough, pressure, and pain. Nerves are
connected throughout the whole body to the brain. These
carry the information throughout the body in the form of
electrochemical signals called impulses. These impulses
travel from the brain and spinal cord to the nerves located
throughout the body. It is largely made up of specialized
cells called neurons, they are the basic unit of the nervous
system, a neuron is a single cell with the cell body,
sometimes is called the Sonoma, one more imput fibers
called dendrites, a long transmitting fiber called the axon.
Each of this neuron has a cell body, or cyton, which
contains the nucleus and organelles. It takes the corporation
of three system to carry out the mission of the nervous
system. These are the central, the peripheral, and the
autonomic nervous systems [15].
Figure 27. Open MRI [43].

July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez BB-25
This machine allows clinicians to conduct advanced
procedures, including, high-resolution routine imaging, all
forms of vascular imaging techniques including 2D/3D
TOF, PC and CE. MRA, high-resolution (RF refocused)
EPI, breath-hold imaging (abdomen and chest); a wide
range of pulse sequences usually associated with high-field
systems; Bolus tracking (optional on Excelart).
Superconducting speed and performance are combined with
the patient access advantages of open MRI design for
unmatched clinical versatility. OPART incorporates the
latest advances in gradient, RF and computer technology to
deliver advanced clinical applications, such as MR
Cholangio-Pancreatography, MR Myelography and MR
Urography, and Images of the highest diagnostic clarity.
The system's superconducting magnet provides all of these
studies with OPART's four sided open design. This implies
that a broader patient population can be accommodated. It’s
all around patient access enables the scanning of large,
claustrophobic or pediatric patients. And also allows for
examinations which are not possible in many closed
systems OPART features a sophisticated icon based user
interface that allows intuitive operation, enabling high
patient tohroughput and allowing routine examinations to
be conducted quickly and efficiently [15].
CAT Scan
This system uses X rays and computers to produce three-
dimensional images of the human body( figure 27). It
provides detailed views of the body’s soft tissues, including
blood vessels, muscle tissue, and organs, such as the brain.
A CAT of the brain can show if an accident victim has
sustained a brain injury, or if bleeding is occurring in the
brain. It also may be used to determine the location and size
of a cancerous tumor and whether the cancer has spread to
other parts of the body. A new application for the CT
include CT angiography, which provides detailed images of
the interior of small blood vessels and images of the
interior of hollow structures, such as the colon and the
airways of the lungs [15].
To enhance image, patients may be given an injection of a
substance that will increase the contrast between different
tissues. The patient can be also asked to drink a liquid that
makes internal organs more clearly and visible in the CT
scan. The CT scan contains an X-ray source, which emits
beams of the X-rays that pass through the patient and are
recorded on the other side by the detector. As the source
and the detector rotate in a 360- angle circle around the
patient, X-ray emissions are recorded from many angles.
Then the computer interprets the data, it translates the
images that appear as cross-sections on a television monitor
[15].
A system so powerful its potential once seemed
unattainable. With more elements and thinner slices, CAT
offers images with remarkable clarity and detail, as well as
more rapidly scans a larger coverage area. Toshiba CT
systems feature expanded clinical applications and system
utility to meet the advanced needs of cardiology, trauma
care, surgery, pediatrics and oncology. Toshiba’s
technology offerings address these needs with: multi-slice
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
technology and one-half second scanning enable faster and
more precise CT imaging. It provides high-performance
CT angiographies with multi-slice, half-second acquisition.
Precision in CT scanning and intervention are attained by
use of Aspire CI technology. Cardiac gating offers
capabilities to provide cost-effective, fast and simple
coronary artery screening. The advanced CAT Aquilion is
engineered for 1/2 second, multi-slice scanning [15].
Patients can be scanned faster clinical exploration.
Furthermore, the Aquilion platform can be enhanced at a
future date, without replacing the gantry, by the addition of
multi-slice scanning capability. Electroencephalogram
(EEG)with much more anatomical detail, since the
Aquilion is redesigned to withstand the g-forces created by
the incredible speed of 1/2 second scanning. The Aquilion
can be combined with Aspire CI for improved CT
interventional applications, and shatter the limits of
Electroencephalogram is the measurement of the electrical
activity of the brain. The measurements are obtained from
electrodes placed on the surface of the scalp. For clinical
measurements, surface or subdermal needle electrodes are
used. The ground reference electrode is often a metal clip
on the earlobe. A suitable electrolyte paste or jelly is used
in conjunction with the electrodes to enhance coupling of
the ionic potentials to the input of the measuring device. To
reduce interference and minimize the effect of electrode
movement, the resistance of the path through the scalp
between electrodes must be kept as low as possible [15].
Normal patterns on the electroencephalogram, or EEG,
include the alpha wave, indicative of a relaxed state, and
the theta wave, usually found in children and thought by
some to reflect creative activity in adults. Medically the
most important use of electroencephalography is to aid in
the diagnosis of epilepsy. The EEG tracing can identify a
specific site at which damage to the brain has occurred.
Study of EEGs has contributed to research into the nature
of sleep, helping to identify four stages of sleep. Scientists
have also analyzed brain waves stimulated by sensory
input, such as a flash of light or a sound, as a means of
determining which parts of the brain carry out various
functions [15].
Figure 28. CT Scan [43].
BB-26
Most clinical electroencephalographs provide the capability
of simultaneously recording EEC signals from several
regions of the brain. The readout in a clinical
electroencephalograph is a multichannel pen recorder with
a pen for each channel. The standard chart speed is 30
mm/sec, but most electroencephalographs also provide a
speed of 60 mm/sec for improved detail of higher-
frequency signals. Many electroencephalographs also have
provisions for interfacing with an analog tape recorder to
permit recording and playback of the EEG signal.
Dedicated cardiology imaging system Features improved
patient throughput with 180°, 90° or 76° myocardial Spect
Acquisition. Real-time infrared body contouring reduces
setup time [15].

The electrode sock

Patients with diabetic foot pain, sprains and fractures in the

feet, ankles and other pediatric ailments now have an easy,
at-home, treatment option: the Electrode Sock. The sock
provides stimulation to the entire foot and ankle to increase
blood flow, thereby reducing swelling and associated pain
[43].

Transcutaneous electrical nerve stimulator (TENS)

TENS is an acronym for Transcutaneous Electrical Nerve

Stimulation. Developed in the late 1960’s, the TENS
stimulator is a battery-powered device which transmits an
electrical impulse through lead wires and surface electrodes
to underlying nerves. The stimulator converts the direct
current of the battery into pulses of stimulation. Most
stimulators feature adjustable settings to control amplitude
(intensity) of stimulation by controlling voltage, current,
and pulse width (duration) of each pulse [43].
Electrodes are placed at specific sites on the body for
treatment of pain. The current travels through electrodes
and into the skin stimulating specific nerve pathways to
produce a tingling or massaging sensation that reduces the
perception of pain. When used as directed, TENS is a safe,
non-invasive, drug-free method of pain management [43].
Microcurrent electrical neuromuscular stimulator
MENS use a very low voltage current, usually between 1
µA and 1000µA. A microamp (µA) is 1/1000 of a milliamp
(mA), so 1000 µA equals 1 mA. Most TENS devices have
a milliamplitude of 1-80 mA. Where TENS is used to hide
pain, microcurrent, is thought to work on a more cellular
level. It has been theorized that healthy tissue is the result
of the direct flow of electrical current throughout the body.
Electrical balance is disrupted when the body is injured at a
particular site, causing the electrical current to change
course. The use of Microcurrent over the injured site is
thought to realign this flow, thus aid in tissue repair. It's
been found that ATP (Adenosine Triphosphate) in the cell
helps to promote protein synthesis and healing [43].
Figure 29. Electroencephalogram [43].
The lack of ATP due to trauma of the tissue results in the
decreased production of sodium and an increase in
metabolic wastes, which is perceived as pain. The use of
Microcurrent at an injured area helps to realign the body’s
electrical current, increase the production of ATP, resulting
in increased healing and recovery, as well as blocking the
pain that is perceived [43].
Electrical muscle stimulator
EMS is the use of electrical stimulation on muscle groups
to contract and reeducate muscles. Some of the uses of
EMS are as follows: (1) Maintaining and increasing range
of motion in conditions where the reduction of
physiological range of motion is due to or the result of
fractures with consequent immobilization, operative
intervention, or arthroscopy, in shoulders, knees, and backs.
(2) The Prevention or Retardation of muscle Disuse
Atrophy: Muscle disuse atrophy is a reduction 'in muscle
contraction and size due to prolonged impairment or joint
immobility from surgery, injury or disease. The use of
electrical stimulation to contract the muscles builds and
strengthens the muscles, assisting in prevention of disuse
atrophy. (3) Relaxation of muscle Spasms: Muscle
spasms and cramping often occur in areas of localized pain
and tenderness. Stimulation is used to fatigue the "spastic"
muscle. (4) Muscle Reeducation: Evidence has shown that
a combination of both exercise and electrical stimulation is
far superior in strengthening atrophied muscles. Increased
Local Blood Circulation: Rhythmic muscle contraction

July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez BB-27
helps improve blood circulation, thereby aiding in the
reduction of localized swelling and tenderness. (5)
Immediate Post-surgical Stimulation of Calf Muscles to
Prevent Venous Thrombosis: The use of EMS to increase
blood circulation assists in the prevention of venous
thrombosis [43].
High voltage pulsed galvanic stimulation
High-voltage pulsed galvanic stimulation (HVPGS) is
gaining widespread use for wound healing, edema
reduction and pain relief Carpal Tunnel Syndrome and
Diabetic Foot are two major areas of use. Devices in this
class are characterized by a unique twin- peak monophasic
waveform with very short pulse duration (microseconds)
and a therapeutic voltage greater than 100 volts. The
combination of very short pulse duration and high peak
current, yet low total current per second (microcurrent)
allows relatively comfortable stimulation. Furthermore, this
combination provides an efficient means of exciting
sensory, motor and pain-conducting nerve fibers.
Perceptual discrimination of those responses is relatively
easy to achieve and thus its clinical versatility. Background
skin offers a great amount of resistance to the flow of
electrical current. When current is passed through a circuit
that contains resistors, voltage drop occurs and energy is
lost. This phenomenon occurs when traditional low voltage
units are used in treatment A high voltage device produces
a spontaneous breakdown in skin resistance and HVPGS
current passes through the skin with negligible thermal and
electrochemical effects. Bell Telephone Laboratories
developed the first high voltage stimulator in 1945. By
decreasing the pulse duration and increasing the voltage,
the developers noted that deep tissues could be stimulated
without producing tissue damage. The first published report
(I 966) described its effectiveness in wound healing of
animal limbs [43].
Figure 30. The Electrode sock [43].
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
Interferential generator
Interferential electrical stimulation's is a unique way of
effectively delivering therapeutic frequencies to tissue.
Conventional TENS and Neuromuscular stimulators use
discrete electrical pulses delivered at low frequencies of 2-
160 Hz per second. However, Interferential stimulators use
a fixed carrier frequency of 4,000 Hz per second and also a
second adjustable frequency of 4,001-4,400 Hz per second.
When the fixed and adjustable frequencies combine
(heterodyne), these produce the desired signal frequency
(Interference frequency). Interferential stimulation is
concentrated at the point of intersection between the
electrodes. This concentration occurs deep in the tissues as
well as at the surface of the skin. Conventional TENS and
Neuromuscular stimulators deliver most of the stimulation
directly under the electrodes. Thus, with Interferential
Stimulators, current perfuses to greater depths and over a
larger volume of tissue than other forms of electrical
therapy. When current is applied to the skin, capacitive skin
resistance decreases as pulse frequency increases.'
For example, at a frequency of 4,000 Hz (Interferential
unit) capacitive skin resistance is eighty (80) times lower
than with a frequency of 50 Hz (in the TENS range). Thus,
Interferential current crosses the skin with greater ease and
with less stimulation of cutaneous nociceptors allowing
greater patient comfort during electrical stimulation. In
addition, because medium-frequency (Interferential)
current is tolerated better by the skin, the dosage can be
increased, thus improving the ability of the Interferential
current to permeate tissues and allowing easier access to
deep structures. This explains why Interferential current
may be most suitable for treating patients with deep pain,
for promoting osteogenesis in delayed and nonunion
fractures and in pseudothrosis. Also for stimulating deep
skeletal muscle to augment the muscle pump mechanism in
venous insufficiency, and for depressing the activity of
certain cervical and lumbosacral sympathetic ganglia in
patients with increased arterial constrictor tone [43].
Clinical electromyography (EMG)
Clinical electromyography consists of nerve conduction
studies (NCS) and needle electromyography (needle EMG).
In the strict sense of the word, EMG only refers to the
needle electrode examination of muscles, however is has
traditionally been used to refer to both NCS and needle
EMG. It is a diagnostic modality for the evaluating the
peripheral nervous system which, can provide invaluable
information that may not be obtainable with any other
diagnostic test. It can also complement the information
obtained from other sources, such as imaging studies, for
optimal localization of a lesion [43].
There are dozens of muscles and nerves that can be tested,
and it is the electromyographer's job to tailor the
examination to the patient's particular clinical problem.
What is tested is as important as how competently it is
done.
BB-28
Peripheral nerves transmit electrical impulses and can be
simplistically thought of as extremely efficient conductive
wires. For NCS studies, a noninvasive stimulator applies
brief electrical impulses to a peripheral nerve
transcutaneously, the nerve then transmits the impulse and
a response is recorded by electrodes at some distance away.
The time it takes for the stimulus to reach the recording
electrodes (latency) can be accurately measured and a
velocity of transmission calculated. Both motor and sensory
nerves can be examined. Healthy nerves will transmit the
electrical impulse faster than diseased ones [43].
Needle EMG does not introduce any electrical stimulation,
instead it records the intrinsic electrical activity of skeletal
muscle fibers. The needle is quite slim (about a 25 gauge)
and produces minor discomfort which most patients can
tolerate. Needle EMG findings suggestive of denervation
include:
1. Fibrillations,
2. Positive sharp waves, and
3. Giant motor unit potentials (MUP).
Abnormalities pointing to a myopathy include small short-
duration MUP. Since the root and peripheral nerve supply
to the muscles is known, needle EMG can be used to
localize peripheral nerve or root lesions by noting which
muscles show denervation changes.
For most conditions, NCS and needle EMG complement
each other and are performed in the same session.
Figure 31. Electromyography machine [43].
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
Carpal tunnel syndrome (CTS)
CTS is the single most common referring diagnosis in the
EMG laboratory and by far the most common entrapment
neuropathy. Electrophysiological features include:
1. Prolongation of the median nerve motor latency
upon stimulation at the wrist ("terminal" or
"distal" latency).
2. Normal median motor conduction velocity in the
forearm.
3. Slow median sensory conduction velocity across
the wrist.
Normal motor and sensory NCS of the ulnar nerve (not
involved in CTS). NCS are positive in 91-98% of patients
with clinical CTS8 [43].
Although false negatives do occur, those are so infrequent
that the diagnosis should be reconsidered. An
asymptomatic contralateral CTS can be seen in 32% of
patients [43].
Ulnar neuropathy
The second most frequent entrapment neuropathy is ulnar
neuropathy at the elbow. Entrapment at the wrist is much
less frequent. An useful clinical tip in making a distinction
is that when the lesion is at the wrist, only the sensation in
the palm is affected, whereas with a lesion at the elbow
both the palm and the dorsum of the hand are numb. This is
so because the ulnar nerve branch which supplies sensation
for the dorsum of the hand (dorsal ulnar cutaneous nerve)
leaves the main trunk of the ulnar nerve at the forearm so it
would not be involved in lesions at the wrist [43].
The cardinal EMG findings in elbow involvement are:
1. Sslowing of ulnar motor conduction velocity
across the elbow.
2. Conduction block across the elbow segment.
3. Needle EMG evidence of denervation in ulnar-
innevated muscles.
Peripheral neuropathy
In this group of conditions the peripheral nerves are
affected in a diffuse fashion and more or less
symmetrically. This is distinguished from entrapment
neuropathies where only one nerve is affected. In the USA
the most common etiologies are diabetes mellitus (by far
the most frequent), alcohol abuse, and uremia. In third
world countries, leprosy is one of the leading causes. EMG
features of peripherial neuropathy include:
1. 1.Diffuse slowing of nerve conduction velocity in
sensory and/or motor nerves, usually worse in the
lower limbs,
BB-29
 2. 2.Sensory nerves are usually affected earlier than Table 1. Conditions referred for EMG.
motor ones,
Yield of EMG
3. 3.Needle EMG evidence of denervation in distal Condition Comment
EMG Features
muscles is not always present and is not essential
for the diagnosis. NCS are diagnostic in 80 % of + median
cases8. n. TL, Most common
CTS 91-98% + median entrapment
SCV, nl neuropathy
Apart from establishing the diagnosis, NCS can also be ulnar NCS
helpful in suggesting the etiology of the neuropathy.
Peripheral neuropathies are classified as "axonal" or Ulnar slow MCV Wrist
"demyelinating", depending on which part of the nerve is Neuropathy 73-91% across entrapment is
most affected by the disease process. The great majority of (elbow) elbow, CB less frequent
polyneuropathies are of the axonal type. Only a handful are Diabetes most
demyelinating, so finding NCS features of demyelination diffusely common
really narrows down the differential diagnosis6,8. Examples Polyneuropathy >80%
slow etiology in
of demyelinating peripheral neuropathies include: Guillain- USA
Barre syndrome, chronic demyelinating neuropathy, and
polyneuropathy associated with gammopathy [43]. denervation
in EMC not
Radiculopathy 80-100% paraspinals positive before
Cervical and lumber radiculopathy
and 7-20 days
myotome
Needle EMG is essential to establish the diagnosis. NCS
are usually normal in radiculopathies, but are required to small-short Polymyositis is
Myopathy varies*
exclude concurrent peripheral neuropathy or MUP most common
mononeuropathy which may affect the needle EMG
examination. EMG features include:
The yield of EMC varies with the etiology and severity of
1. Needle EMG evidence of denervation involving the myopathy ABBREVIATIONS: n. = nerve, TL =
paraspinal muscles and, terminal latency, NCS = nerve conduction studies, SCV =
2. Denervation involving limb muscles of the same sensory conduction velocity, MCV = motor conduction
root innervation (myotome). The yield is at least velocity CB = conduction block, MUP = motor unit
80%. potentials

Myopathy

In adults, polymyositis is the most common cause of Both NCS and needle EMG are only mildly uncomfortable
acquired myopathy. Needle EMG is essential for diagnosis. to most patients. No special preparation is required for the
NCS are performed for the same reasons as in test, except to avoid applying oils or lotions on the skin as
radiculopathies [43]. it interferes with electrode adherence.

In cases of radiculopathy, if a specific root level is
suspected, mention it. For entrapment neuropathies, include
the nerve and the suspected site of involvement (wrist,
elbow, etc.). A short pertinent clinical history is also very
helpful. Important conditions to mention are diabetes
mellitus, alcoholism, uremia, cancer, and collagen vascular
diseases. In general, any severe systemic disease is worth
mentioning. It is best to request both NCS and needle EMG
since these usually complement each other [43].
As with any other ancillary medical test, clinical correlation
is crucial. It should be ask if the EMG diagnosis makes
sense with the clinical picture? An inadequately performed
or interpreted EMG can become a nightmare and lead to
unnecessary procedures and even surgery1. If the EMG
diagnosis is confusing, discuss it with the
electromyographer or request a formal neurological or
neurosurgical consultation. As with everything else in
medicine, common sense is the key [43].

The time of onset of symptoms is very important since
needle EMC evidence of denervation takes at least 7-10
days to develop following nerve injury 7. Thus, a negative
needle EMG examination done within 10 days of the onset
of symptoms should be repeated later. A two weeks interval
is recommended to be certain that enough time has passed
for needle EMG findings to be detectable [43].
THE URINARY SYSTEM
The human body has several systems to remove waste. The
urinary system produces and discharges urine. The kidneys
play a vital role within the urinary system by filtering out
water and waste from the blood. These waste materials are
excreted (eliminated) by the kidneys in the form of urine
[22].

July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez BB-30
An adult bladder holds about 1 pint (475ml) of urine. You
excrete anywhere from 1.5 - 3.5 pints (.7 to 2 liters) of
urine a day. Did you know that sweat is made up of the
same substances as urine? That's right! Although they
contain different concentrations of water, salt, and urea,
sweat and urine are made up of the same stuff [11].
The cystoscope [22]
Cystoscopy is a procedure that enables your health care
provider to view the inside of your bladder and urethra in
great detail using a specialized endoscope (a tube with a
small camera used to perform tests and surgeries) called a
cystoscope [22].
1. How is the test iperformed?
There are two types of cystoscopes, the standard rigid
cystoscope and the flexible cystoscope. The method for
insertion of the cystoscope varies, but the test is the same.
The choice of which scope to use depends on the purpose
of the exam.
If the standard rigid cystoscope is used, you lie in the
lithotomy position (on back with your knees up and apart).
The flexible cystoscope may be easier to insert than the
standard rigid model. It does not require the lithotomy
position for insertion.
The procedure usually takes between 5 and 20 minutes. The
urethra is cleansed and a local anesthetic is applied. The
scope is then inserted through the urethra into the bladder.
Water or saline is inserted through the cystoscope and fills
the bladder. As this occurs, you are asked to describe the
feeling to your health care provider, which provides
information about your condition [22].
As the fluid fills the bladder, it stretches the bladder wall,
enabling the physician to view the entire bladder wall. You
will feel the sensation of a need to urinate when the bladder
is full; however, it needs to remain full until the
examination is complete [22].
If any tissue appears abnormal, a small specimen can be
taken (biopsy) through the cystoscope to be analyzed.
2. Why the test is performed ?
1. Diagnose and evaluate urinary tract disorders
2. Check for cancer of the bladder or urethra
3. Diagnose an enlarged prostate (men)
4. Help determine the cause of pain during urination
5. Diagnose recurrent bladder infections
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
Figure 32. Endoscope [43].
3. Normal Values
The bladder wall should appear smooth. The bladder
should be normal size, shape, and position. There should be
no obstructions, growths, or stones.
4. Special considerations
One may notice a small amount of blood in the urine
following this procedure. If the bleeding continues after
three voids (urinations), contact the health care provider.
There is also a chance of infection. If one develops pain,
chills, fever, or reduced urine output, contact ther health
care provider.
Endoscope [22]
What is Endoscope and Why is it Performed?
Endoscope allows physicians to peer through the body's
passageways. Endoscope is the examination and inspection
of the interior of body organs, joints or cavities through an
endoscope.
An endoscope is a device using fiber optics and powerful
lens systems to provide lighting and visualization of the
interior of a joint. The portion of the endoscope inserted
into the body may be rigid or flexible, depending upon the
medical procedure [22].
An endoscope uses two fiber optic lines. A "light fiber"
carries light into the body cavity and an "image fiber"
carries the image of the body cavity back to the physician's
viewing lens. There is also a separate port to allow for
administration of drugs, suction, and irrigation. This port
may also be used to introduce small folding instruments
such as forceps, scissors, brushes, snares and baskets for
tissue excision (removal), sampling, or other diagnostic and
therapeutic work. Endoscopes may be used in conjunction
with a camera or video recorder to document images of the
inside of the joint or chronicle an endoscopic procedure.
New endoscopes have digital capabilities for manipulating
and enhancing the video images [22].
A rigid endoscope (Figure 30) is used for arthroscopy. The
"image fiber" leads from the ocular (eye piece) to the
inserted end of the scope. The "light fiber" is below and
BB-31
leads from the light source to the working end of the small volume doses - less than 10 cc. Use a 16 gauge for
endoscope. large volume doses of 10 cc or greater [7].

Why Is Endoscopy Performed?
Endoscope can be used to diagnose various conditions by
close examination of internal organ and body structures.
Endoscope can also guide therapy and repair, such as the
removal of torn cartilage from the bearing surfaces of a
joint. Biopsy (tissue sampling for pathologic testing) may
also be performed under endoscope guidance. Local or
general anesthetic may be used during endoscope,
depending upon the type of procedure being performed
[22].
Internal abnormalities revealed through endoscope include:
abscesses, biliary (liver) cirrhosis, bleeding, bronchitis,
cancer, cysts, degenerative disease, gallbladder stones,
hernia, inflammation, metastatic cancer, polyps, tumors,
ulcers, and other diseases and conditions [22].
Endoscope is a minimally invasive procedure and carries
with it certain minor risks depending upon the type of
procedure being performed. However, these risks are
typically far outweighed by the diagnostic and therapeutic
potential of the procedure [22].
Prior to the widespread use of endoscope and diagnostic
imaging, most internal conditions could only be diagnosed
or treated with open surgery. Until the last several decades,
exploratory surgery was routinely performed when a
patient was critically ill and the source of illness was not
known. For example, in certain dire cases the patient's
thorax or abdomen were surgically opened and examined to
try to determine the source of illness [22].
Needles of course come in different lengths. When drawing
blood from pigs you will be using a needle that is 6 inches
long! Drawing blood from the neck of a sheep or the tail
vein of a cow is usually done with a 1 inch needle. For
intramuscular injections a 1 inch needle is commonly used
with young animals while a 1.5 inch needle would be used
in adults. For subcutaneous injections a .5 to 1 inch needle
is favored [22].
The viscosity of the product also plays a part in gauge
selection. If the product is "thick" and pushes through the
needle hard, opt for the 16 gauge needle even for the small
dose. If selecting one needle for all-around performance, a
1-inch, 16 gauge needle works well. Its a good all around
needle that meets the requirements of intramuscular and
subcutaneous injections. When using needles for injections
it is best to change them every 10 to 15 injections, or each
time you stop to refill an automatic syringe. Dull needles
cause excess issue damage. which increases the chances of
reactions and abscesses forming. Also, over used needles
can become dirty and spread germs. Never just throw away
used needles. They need to be stored in a "sharps"
container. This is a plastic box used to store needles until
they can be properly disposed of. Often, the veterinarian
can or a local hospital or the local public health office can
remove and replace the container [22].

Endoscope can often be done on an outpatient basis.

"Outpatient" means that the procedure does not require
hospital admission and acute care and observation and may
be performed outside the premises of a hospital. Outpatient
procedures performed at hospitals or ambulatory centers
allow the patient to go home or return to work within a
short while after their procedure [10].
Figure 33. Needles [30].
Needles and syringes

Needles have evolved over the years so that today they

come in many different sizes and diameters, or gauges.
Needles also have different bevels on the tip to better do
the jobs they are used for. Gauges run from 4 to 30 , with
the smaller number being the largest around. A four gauge
needle would be used to insert an t6rocar with a 10 gauge
used to place a catheter in a jugular vein of a cow. On the
other end of the scale a 30 gauge needle would be used by a
dentist to give you Novocain before drilling your brains
out. The most commonly used gauges of needles in
domestic animal production would be in the 16 to 22 range
with 18 the most common. Use an 18-gauge needle for
Figure 34. Syringes [31].

July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez BB-32
Syringes also have evolved over the years. Today there are
many sizes and shapes of syringes. Many are specialized,
or used for just one thing. Basically there are just two types
though. Syringes that are made to be disposed of after one
use, and those that are made to be used many times [7].
Disposable syringes are in theory used only one time and
then discarded. The syringe used to draw blood from a
human probably falls under this description. However,
plastic, disposable syringes are the backbone of many
livestock producers health programs [7].
Automatic or re-usable Syringes. are made to be used for
many years . They must be maintained with proper cleaning
and storing if they are to do so however [7].
Haemodialysis treatment
Dialysis means the replacement of the excretory function of
the kidneys by artificial means. Dialysis is only necessary
when the kidneys have failed. There are two principal
forms of dialysis - haemodialysis and peritoneal dialysis.
This Fact Sheet addresses haemodialysis. Haemodialysis is
the process whereby blood is pumped from the patient
through an artificial kidney (called a dialyser) and back to
the patient [7].
1. What type of dialysis should be used?
The choice between haemodialysis or peritoneal dialysis
depends upon many factors including the availability of
resources, age, overall health and lifestyle. The advantages
and disadvantages of each type of dialysis need to be
weighed up in consultation with the clinical team caring for
the person with kidney failure and their family. It is
possible to change from haemodialysis to peritoneal
dialysis or vice versa if it is found that the initial treatment
option does not suit the person or their lifestyle. Discussion
with your nephrologist is essential if a treatment change is
desired [7].
2. What happens during haemodialysis?
As with peritoneal dialysis, haemodialysis replaces lost
kidney function. During haemodialysis, an artificial kidney
machine (or "dialysis machine") replaces the excretory
function of the failed kidneys. Blood from the patient is
pumped from the body through special tubing to the
dialysis machine, where it travels through the dialyser and
back to the patient. The dialyser replaces some of the
balancing functions of the native kidney. To do this access
to the patient’s blood supply is needed. This is achieved by
the creation of a fistula or graft and is usually placed in the
forearm [7].
For each treatment, the patient sits next to the machine.
Two needles are inserted into the fistula or graft - one takes
blood to the machine, the other returns blood to the patient.
During treatment, the blood in the body flows through the
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
dialyser, which is connected to the dialysis machine. A
pump on the machine, assisted by the body's blood
pressure, moves the blood through the tubing and dialyser.
Only about 300ml (approximately 2 cups) is out of the
body at any one time. The blood is pumped at around 2-300
mls per minute and over a four hour dialysis session the
whole 5 litres of blood in the average person’s body will
flow through the artificial kidney approximately six times.
Haemodialysis is usually performed three times a week at
regularly spaced intervals. Dialysis sessions usually last 4-6
hours [7].
3. What are dialysers (artificial kidney) and dialysate?
The dialyser is a plastic cylinder that contains thousands of
very fine tubes or fibres. Each of these has tiny pores in its
walls, only small enough for waste and extra fluid to pass
through. Blood cells and protein cannot fit through the
holes. Blood is pumped to the dialyser and flows through
the fibres. A specially formulated fluid called ‘dialysate’
washes around the outside of the fibres. Dialysate has a
similar chemical composition to healthy blood, so the
electrolytes (which are unbalanced in renal failure) can
equilibrate and be returned to the normal range. The used
dialysate goes down the drain into ordinary sewage waste
[7].
4. Is haemodialysis painful?
Haemodialysis is not painful. The patient does not feel the
blood being moved through the dialyser. A local
anaesthetic is often used prior to the insertion of the
needles. The fistula arm with the needles in it must be kept
reasonably still. People on haemodialysis can read, talk,
play board or card games, watch television, write, use a
computer or sleep. They cannot get up and move around
[7].
5. For how long must a person continue dialysis treatment?
Dialysis must be performed for the rest of a persons life or
until they receive a kidney transplant.
6. Extracorporeal blood circuit
Figure 35. Flow Traces in a Centrifugal pump [18]
BB-33

Figure 36. Pressure contours in a Axial Blood flow pump
[18].
Several bloodflow pumps have been successfully
characterized using figure 18, including axial and
centrifugal pumps. CFD analysis has been used to quantify
stress and hemolysis (using the built-in hemolysis model)
levels in several blood pumps.. Multiple designs of blood
flow pumps have been virtually prototyped for performance
optimization [18].
THE ENDOCRINE SYSTEM
The endocrine system is a group of organs and body tissues
that produce, store, and secrete chemical substances known
as hormones. Hormones are the body’s chemical
messengers and transfer information and instructions from
one set of cells to another. Endocrine organs have a great
deal of influence over body thanks to the hormones. Their
job is to regulate the body’s growth and development, the
control of the function of various tissues, the support of
pregnancy and other reproductive functions, and the
regulation of metabolism [5].
To study the system, the observer performs a blood analysis
that indicates any endocrine alteration. A technique used
for diagnosis of the endocrine diseases is the
radioinmunoanalysis. It is based on the usage of specific
antibodies for a determined hormone. A urine analysis is
also used to quantify parameters in the diagnostic of
endocrine diseases such as glucosuria or concentration of
glucose in urine, present in diabetes. It can also determine
the quantity of hormones excreted by their urine that gives
an idea of the functioning of the endocrine glands. The X-
rays are used to observe the endocrine glands; to see their
shape and size to determine any disorder on them. Some
visual tests are also performed for diagnosis of some
complications [5].
MICROSCOPE
The instrument that produces enlarged images of small
objects, allowing them to be viewed at a scale convenient
for examination and analysis, is called the microscope.
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
Optical, acoustic, or electronic means, and direct imaging,
electronic processing may form the image, or a
combination of these methods receives it. The microscope
may be static, in which the object is viewed directly, or
dynamic, in which the image is built up by successive scans
of the object [5].
The magnifying power of a microscope is an expression of
the number of times the object being examined appears to
be enlarged. Magnifying power is a dimensionless ratio.
The resolution Microscopeof a microscope is a measure of
the size of the smallest detail on the object that can be
observed. Resolution is expressed in linear units, usually
millimeters [5].
The most familiar type of microscope is the optical, or
light, microscope, in which lenses are used to form the
image. Optical microscopes can be simple, consisting of a
single lens, or compound, consisting of several optical
components in tandem. Simple optical magnifiers may have
magnifying powers of from 1 to 10 magnitudes, with
resolutions to about 0.01 millimeter (mm) possible.
Compound optical microscopes have magnifying powers
ranging from about 2.5 to 1,000 magnitudes and provide
resolutions of 0.01 to 0.0002 mm [5].
Other types of microscopes utilize the wave nature of
various physical processes, the most important being the
electron microscope, which uses a beam of electrons in its
image formation. Electron microscopes have magnifying
powers of 1,000 to 1,000,000 magnitudes possible, with
resolutions ranging from 0.001 to 0.000 000 01 mm.
Special microscopes, such as acoustic microscopes or
scanning tunneling microscopes, use other physical effects,
further extending the range of objects that can be
viewed.Indeed, with a scanning tunneling microscope, even
individual molecules and atoms can be seen [5].
PHYSICAL THERAPY
High voltage pulsed galvanic stimulation
HVPG stimulation is a treatment modality to decrease pain
and swelling. Galvanic stimulation is direct current (DC),
moving fluid from the affected area back into circulation. It
can be used to treat and provide therapeutic relieve from
the following indications: relaxation of muscle spasm,
arthritic pain, increasing local blood circulation, and
maintaining or increasing range of motion. It is also very
good in edema reduction, reducing motor spasticity,
preventing or retarding disuse atrophy and managing post
traumatic or post surgical pain conditions, and it is ideal
when used in therapy for carpal tunnel syndrome [43].
The Thera Tech Equipment has two types of portable
galvanic stimulators designed for home use and offers
conventional electrodes, as well as, the complete line of
electromesh garments. The sterling impulse is powered by
a 9-volt battery system, single alkaline work best. It records
from 6 minutes to 999.9 hours in 6-minute increments [43].
In order to prevent the patient from wearing the stimulator
to long, an automatic shut-off feature is incorporated. The
BB-34
glove also supplies electrostimulation from a Pulsed-
Galvanic Stimulator and other stimulation modalities [43].
Ectrica1 stimulating currents
The electrical stimulating currents that affect nerve and
muscle tissue have the longest wavelengths and the lowest
frequencies of any of the modalities. The wavelengths of
electrical stimulating units are extremely long, ranging
somewhere around 15,000 km (clinically used frequencies
range from 1 to 2000 Hz). Most stimulators have the
flexibility to alter the frequency output of the device to
elicit a desired physiologic response. The nerve and muscle
stimulating currents are capable of pain modulations either
through stimulation of cutaneous sensory nerves at high
frequencies or through production of β-endorphin at lower
frequencies, producing muscle contraction and relaxation
or tetany depending on the type of current (alternating or
direct) and frequency, and producing a net movement of
ions and thus eliciting a chemical change (direct current
only) [43].
Infrared modalities
The infrared modalities are used to produce a local and
occasionally a generalized heating or cooling of the
superficial tissues. It is generally accepted that the infrared
modalities have a maximum depth of penetration of 1 cm or
less. The infrared modalities can elicit either increases or
decreases in circulation depending on whether heat or cold
is used. They are also known to have some analgesic
effects as a result of stimulation of sensory cutaneous nerve
endings [43].
The wavelengths of the infrared modalities are much
shorter than are those of the electrical stimulating cur rents
and the diathermies and are expressed in Angstrom (Å)
units; 1 Å is equal to l0 meters (m).
The infrared and ultraviolet wavelengths are temperature
dependent. Those modalities with the lower temperature
have the longer wavelength. Temperatures used with the
infrared modalities range from 0° C with ice to more than
3000° C with the infrared lamps. The wavelengths in this
temperature range fall between 10,000 and 105,000 Å with
corresponding frequencies ranging between 2 x 1012 and 4
x 1013 Hz [43].
The critical factor is the superficial increase or decrease in
tissue temperature that elicits the same physiologic
response regardless of wavelength [43].
Shortwave and microwave diathermy
The diathermies are considered to be high-frequency
currents because they have more than a million cycles per
second. When impulses of such a short duration come in
contact with human tissue there is not sufficient time for
ion movement to take place. Consequently there is no
stimulation of either motor or sensory nerves. The energy
of this rapidly vibrating electrical current produces heat as
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
it passes through tissue cells, resulting in a temperature
increase [43].
The electrotherapeutic shortwave and microwave devices
have preset frequencies and wavelengths that cannot be
altered. Shortwave diathermy units are set at either 13.56
MHz with a corresponding wavelength of 22 m or 27.12
MHz with a wavelength of 11 rn.
Microwave units have shorter wavelengths than do
shortwave diathermy units and are set at wavelengths of 33
or 12 cm with respective frequencies of 915 or 2450 MHz.
The depth of penetration with microwave is bit deeper than
with shortwave because the amount of energy when using
microwave is concentrated in one spot rather than spread
out over a large area [43].
Ultraviolet therapy
The physiologic effects of ultraviolet are mainly chemical
in nature and occur entirely in the cutaneous layers of skin.
The maximum depth of penetration with ultraviolet is about
1 mm. Ultraviolet wavelength ranges between 1850 and
4000 Å. The ultraviolet region is subdivided into two
different areas; near ultraviolet (2900 to 4000 Å) and far
ultraviolet (1850 to 2900 Å). Clinically used frequencies
with ultraviolet range between 7 X 1013 and 7 x 1014 Hz.
Ultraviolet therapy is used rarely by the sports therapist to
treat cutaneous lesions [43].
The acoustic spectrum and ultrasound
Ultrasound devices produce a type of energy that must be
classified as a portion of the acoustic spectrum rather than
the electromagnetic spectrum. Ultrasound is frequently
classified along with shortwave and microwave diathermy
as a deep-heating conversion type modality, and it is
certainly true that all of these are capable of producing a
temperature increase in human tissue to a considerable
depth. However, ultrasound is a mechanical vibration, a
sound wave, produced and transformed from high-
frequency electrical energy [43].
Acoustic and electromagnetic radiations have very different
physical characteristics. When acoustic vibrations are
produced, they travel at a velocity that is significantly
lower than electromagnetic radiations. Electromagnetic
waves travel at approximately 300 million meters per
second while sound waves travel at speeds from hundreds
to several thousand meters per second [43].
Frequencies of ultrasound wave production are between
700,000 and 1,000,000 cycles per second. The depth of
penetration with ultrasound is much greater than with any
of the electromagnetic radiations. At a frequency of 1
megacycle, 50% of the energy produced will penetrate to a
depth of about 5 cm. The reason for this great depth of
penetration is that ultrasound travels very well through
homogeneous tissue while electromagnetic radiations are
almost entirely absorbed. Thus when therapeutic
penetration to deeper tissues is desired, ultrasound is the
modality of choice [43].
BB-35
Clinical ultrasound is capable of producing a temperature
increase in the deeper tissues and thus to some extent pain
relief as a result of both mechanical and chemical effects.
Electrical treatments
Electrical treatments can provide dramatic results at times.
The use of electricity in treating an injury can be beneficial,
but the therapist must base the use of electricity on factual
information about the effects of electricity on biologic
tissues. Electrical therapy should not be used in a shotgun
approach if we are to maximize the effectiveness of this
modality [43].
All biologic tissue will have some response to having an
electrical current passed through it. The type and extent of
this response are dependent on the type of tissue and its
response characteristics, and the nature of the current
applied. The tissue should respond to electrical energy in a
manner similar to the manner in which it normally
functions or grows. This is essential in the use of any
therapeutic modality. Clinically, therapists use electrical
currents for:
• Creating muscle contraction through nerve or
muscle stimulations.
• Stimulating sensory nerves to help in treating
pain.
• Creating an electrical field in biologic tissues to
stimulate or alter the healing process.
• Creating an electrical field on the skin surface to
drive ions beneficial to the healing process into or
through the skin.
Muscle and nerve responses to electrical currents
The major therapeutic use of electricity is concentrated
around muscle contraction or sensory stimulation or both.
Nerve and muscle are both excitable tissues. This
excitability is dependent on the cell membrane’s voltage
sensitive permeability. Nerve or muscle cell membrane
regulates the interchange of substances between the inside
of the cell and the environment outside the cell. The cell
membrane allows certain ions to move freely into or out of
the cell while almost totally keeping other ions in place
outside or inside the cell. This voltage sensitive
permeability creates an unequal distribution of charged ions
on each side of the membrane, which in turn creates a
potential difference between the charge of the interior of
the cell and the exterior of the cell. The membrane is then
considered polarized. The potential difference between
inside and outside is known as the resting potential because
the cell tries to maintain a homeostatic, or balanced,
electrical relationship between the inside and outside of the
tissue. Both electrical and chemical equilibrium must be
established along the membrane; that is, the net movement
of ions into the cell is equaled by the net movement of ions
out of the cell. The cell continually moves Na ions out of
the cell and K to the inside of the cell by active transport to
maintain this equilibrium. In addition to the ability of the
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
nerve and muscle cell membranes to develop and maintain
the resting potential, the membranes are excitable [43].
To create transmission of an impulse in the nerve tissue,
there must be a reduction in this resting membrane
potential below a threshold level. Changes in the
membrane’s permeability then occur. These changes create
an active potential that will propagate the impulse down the
nerve in both directions from the location of the stimulus
[43].
An action potential is created by a stimulus from chemical,
electrical, thermal, or mechanical means. The stimulus
always creates the same result, membrane depolarization.
Not all stimuli are effective in causing this depolarization.
To be an effective agent, the stimulus must have an
adequate intensity and last long enough to equal or exceed
the membrane’s basic threshold for excitation. The stimulus
must alter the membrane so that a number of ions are
pushed across the membrane, exceeding the ability of the
active transport pumps to maintain the resting potentials. A
stimulus of this magnitude forces the membrane to
depolarize and results in an action potential [43].
Clinical response to electrical currents
When an electrical system is applied to the soft tissues of
an extremity, the system provides the force to induce ion
movement in the tissues and create an action potential. At
the positive electrode (also called the anode), positive ions
are repelled and negative ions are attracted. At the negative
electrode (also called the cathode), the negative ions are
repelled and the positive ions are attracted [43].
Depolarization
As the charged ions move across the nerve fiber
membranes beneath the anode and cathode, membrane
depolarization occurs. The cathode is usually the site of
depolarization. As the concentration of negatively charged
ions increases, the membrane’s voltage potential becomes
low and is brought toward its threshold for depolarization.
The anode makes the nerve cell membrane potential more
positive, increasing the threshold necessary for
depolarization [43].
Depolarization effects
As the nerve impulse reaches its effect on organ or another
nerve cell, the impulse is transferred between the two at a
motor end plate or at a synapse. At this junction, a
transmitter substance is released from the nerve rather than
having the impulse jump from one to another. This
transmitter substance causes the other excitable tissue to
discharge.In terms of muscle excitation, a twitch muscle
contraction would result. This contraction, initiated by an
electrical stimulus, would be the same as a twitch
contraction coming from voluntary activity. Voluntary
muscular activity is different only in the rate and synchrony
(simultaneous response) of the muscle fiber contractions
[43].
BB-36
Muscular responses to electrical current
Stimulation of the motor nerve is the method used in most
clinical applications of electrical muscular contraction. In
the absence of nerve supply, muscle contraction can be
stimulated by an electrical current by causing the muscle
membrane to depolarize [43].
The all or none response is another important concept in
applying electrical current to nerve or muscle tissue. Once a
stimulus reaches a depolarizing threshold, the nerve or
muscle membrane depolarizes and propagation of the
impulse or muscle contraction occurs. This reaction
remains the same regardless of increases in the strength of
the stimulus used. Either the stimulus will cause
depolarization, the all, or the stimulus will not cause
depolarization, the none. There is no gradation of response
other than by recruiting more nerve fibers by stimulation.
The response of the single nerve or muscle is maximal or
none at all [43].
This all or none phenomenon does not mean that muscle
fiber contraction and overall muscle activity cannot be
influenced by changing the intensity, pulses per second, or
duration of the stimulating current. Adjustments in current
parameters can cause muscle fiber contraction [43].
Effects of changes in current parameters
1. The motor nerves are not stimulated by a steady
flow of direct current. The nerve re-polarizes
under the influence of the current and will not
depolarize until a sudden change in current
intensity occurs.
2. If continuous direct current were the only current
mode available, we would get a muscle
contraction only when the current intensity rose
to a stimulus threshold. Once the membrane re-
polarized, another change in the current intensity
would be needed to force another depolarization
and contraction [43].
3. The biggest difference in the effect of alternating
and direct current is the ability of direct current to
cause chemical changes. Chemical effects from
using direct current will only occur when the
stimulus is continuous and it is applied over a
period of time. These chemical changes become
measurable after about 1 minute, but the effect is
cumulative over the total treatment time. This
type of current is available in most low-voltage
equipment [43].
4. The difference between electrically induced
muscle contraction and voluntary muscle
contraction is the asynchrony of firing of motor
units under voluntary control versus the
synchronous firing of electrically stimulated
motor units. Each tune the electrical stimulus is
applied, the same motor units should respond.
This may lead to greater fatigue in the electrically
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
stimulated muscles. Normal firing in voluntary
muscle contraction varies from one moment to
the next because some motor units are
contracting while others are inactive. Voluntary
contractions do not lead to muscular fatigue as
early in the exercise period as electrical
contractions. This synchrony of contraction may
also be important in using electrical muscle
contractions to improve muscular strength [43].
Therapeutic uses of electrically induced muscle
contraction
A variety of therapeutic gains can be made by electrically
stimulating a muscle contraction:
• Muscle reeducation
• Muscle pump contractions
• Retardation of atrophy
• Muscle strengthening
• Increasing range of motion
Any electrical stimulator, high voltage, low voltage,
alternating current, hybrid current, or transcutaneous
electrical nerve stimulating (TENS) units, may be used to
cause muscle contraction. The efficiency and effectiveness
of the treatment can be increased by following the
protocols as closely as possible with available equipment
[43].
Muscle reeducation
Muscular inhibition after surgery or injury is the primary
indication for muscle reeducation. If the neuromuscular
mechanisms of a muscle have not been damaged, then
central nervous system inhibition of this muscle is usually a
factor in loss of control. Muscle contraction can usually be
caused by electrically stimulating the muscle. Forcing the
muscle to contract causes an increase in the sensory input
from that muscle. The patient feels the muscle contract,
sees the muscle contract, and can attempt to duplicate this
muscular response.
Muscle pump contractions
Electrically induced muscle contraction can be used to
duplicate the regular muscle contractions that help
stimulate circulation by pumping fluid and blood through
venous and lymphatic channels back into the heart. One of
the major problems in most traumatic injuries and surgical
interventions is the excessive accumulation of fluid. This
edema is the result of damage to the vascular structure, loss
of normal muscular activity, and dependency of the
extremity. Electrical stimulation of muscle contractions in
the affected extremity can help in reestablishing the proper
circulatory pattern while keeping the injured part protected
[43].
Retardation of atrophy
Prevention or retardation of atrophy has traditionally been
the reason for treating patients with electrically stimulated
BB-37
muscle contraction. The maintenance of muscle tissue, after
an injury that eliminates normal muscular exercise, can be
accomplished by substituting an electrically stimulated
muscle contraction. The electrical stimulation reproduces
many of the physical and chemical events associated with
normal voluntary muscle contraction and helps to maintain
normal muscle function [43].
Muscle strengthening
Muscle strengthening from electrical muscle stimulation
has been used with some good results in patients with
weakness of a muscle group. Several studies also indicate
that strength gain can be achieved [43].
Increasing range of motion
Increasing the range of motion in contracted joints is also a
possible and documented use of electrical muscle
stimulation. Electrically stimulating a muscle pulls the joint
through the limited range. The continued contraction of this
muscle group over an extended time appears to make the
contracted joint and muscle tissues modify and lengthen.
Reduction of contractures in patients with hemiplegia has
been reported, although no studies have reported this type
of use in contracted joints from injuries or surgery [43].
Therapeutic uses of electrical stimulation of sensory
nerves
Clinically efforts are made to stimulate the sensory nerves
to change the patient’s perception of a painful stimulus
coming from an injured area [43].
Electrical stimulation of sensory nerves may stimulate the
release of enkephalin from local sites throughout the central
nervous system and the release of β-endorphin from the
pituitary gland into the cerebral spinal fluid. The
mechanism that causes the release and then the binding of
enkephalin and β -endorphin to certain nerve cells is still
unclear. It is certain that a diminution or elimination of pain
perception is caused by applying an electrical current to
areas close to the site of pain or to acupuncture or trigger
points, both local and distant to the pain area [43].
Electrode placement
When using any of the treatment protocols aimed at the
electrical stimulation of sensory nerves for pain
suppression, there are several guidelines that will help the
practitioner select the appropriate sites for electrode
placement. Transcutaneous electrical nerve stimulation
(TENS) uses similar sized electrodes placed according to a
pattern and moved in a trial and error pattern until pain is
decreased. The following patterns may be used:
• Electrodes may be placed on or around the
painful area.
• Electrodes may be placed over specific
dermatomes, myotomes, or sclerotomes that
correspond to the painful area.
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
• Electrodes may be placed close to the spinal cord
segment that innervates an area that is painful.
• Peripheral nerves that innervate the painful area
may be stimulated by placing electrodes over
sites where the nerve becomes superficial and can
be easily stimulated.
• Both acupuncture and trigger points have been
conveniently mapped out and illustrated. A
reference on acupuncture or trigger areas should
be consulted and the sports therapist should
systematically attempt to stimulate the points
listed as successful for certain areas and types of
path, If they are effective the patient will have de
creased pain. These can also be identified using
an ohm meter point locator to determine areas of
decreased skin resistance.
• Combinations of any of the above systems and
bilateral electrode placement can also be
successful.
• Crossing patterns, also referred to as an
interferential technique, involve electrode
application so that the electrical signals from
each set of electrodes add together at some point
in the body and the intensity summates. The
pulses must arrive at the point to be stimulated at
the same time and with the same wave form and
frequency. The electrodes are usually arranged in
a crisscross pat tern around the point to be
stimulated.
The practitioner should not be limited to any one system
but should evaluate electrode placement for each patient.
The effectiveness of this treatment is closely tied in with
proper electrode placement. As in all trial and error
treatment approaches a systematic organized search is
always better than a shotgun hit and miss approach [43].
Protocol hyper stimulation and β-endorphin
To use the influence of hyper stimulation analgesia and
endorphin release, a point stimulation setup must be used.
A large dispersive pad and a small pad or hand-held probe
point electrode are used in this approach. Electrode
placement is decided. The point electrode is applied and the
intensity is increased until it is perceived by the patient.
The probe is then moved around the area and the patent is
asked to report relative changes in perception of intensity.
When a location of maximum intensity perception is found,
the current intensity is increased to maximum tolerable
levels [43].
A combination of intense point stimulation and
transcutaneous electrical nerve stimulation may be used.
The transcutaneous electrical nerve stimulation applications
should be used as much as is needed to make the patient
comfortable and the intense point stimulation should be
used on a periodic basis. Periodic use of intense point
stimulation gives maximal pain relief for a period of time
and allows some gains in overall pain suppression. Daily
intense point stimulation may eventually bias the central
nervous system and decrease the effectiveness of this type
of stimulation [43].
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Clinical uses of low-voltage uninterrupted direct
current
The application of uninterrupted low-voltage direct current
causes several physiologic changes that can be used
therapeutically. The therapeutic benefits are related to the
polar and vasomotor effects and to the acid reaction around
the positive pole and the alkaline reaction at the negative
pole [43].
There is also a vasomotor effect on the skin, increasing
blood flow between the electrodes. The benefits from this
type of direct current are usually attributed to the increased
blood flow through the treatment area [43].
Promotion of wound healing
Similar direct current has been used to treat skin ulcers that
have poor blood flow. The treated ulcers show accelerated
healing rates when compared to untreated skin ulcers. The
wound areas should be treated for the first 3 days with the
negative electrode at the wound site and the positive
electrode positioned 25 cm from the wound. The negative
electrode and its alkaline reaction seem to inhibit the
growth of bacteria without destroying it. After the initial
negative pole treatment, the electrodes were reversed and
the positive pole was placed in the wound. The positive
pole promotes the migration of skin cells toward the center
of the wound and decreases healing time in these ulcers
[43].
Promotion of fracture healing
The use of uninterrupted low-voltage direct current may be
an adjunctive modality in the treatment of fractures,
especially fractures prone to non-union. Fracture healing
may be accelerated by passing a direct current through the
fracture site. Getting the current into the bony area without
an invasive technique is difficult [43].
Iontophoresis
Direct current has been used for many years to drive ions
from the heavy metals into and through the skin for
treatment of skin infections or for a counter-irritating
effect. There are two techniques of application: (1) an
active pad is applied over gauze that is saturated with a
solution containing the ions, and (2) an immersion
technique in which the active electrode is suspended in a
container of solution, then the part to be treated is
immersed in the container. In both cases, a large dispersive
pad is applied to the patient and the proper polarity of the
active electrode is selected based on the polarity of the ions
in the solution [43].
Mechanisms of heat transfer
Easy application and convenience of use of hot and cold
modalities provide the therapist with the necessary tools for
primary injury care. Heat is defined as the internal vibration
of the molecules within a body. The transmission of heat
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
occurs by three mechanisms: conduction, convection, and
radiation [43].
Conduction occurs when the body is in direct contact with
the heat or cold source. Convection occurs when particles
(air or water) move across the body, thus creating a
temperature variation. The final mechanism is radiation or
the transfer of heat from a warmer source to a cooler source
through a conduct medium such as air. It must also be
pointed out that the body may either gain or lose heat
through any of these three processes of heat transfer. The
infrared modalities use these three methods of heat transfer
to affect a tissue temperature increase or decrease.
Heat modalities are referred to as thermotherapy.
Thermotherapy is used when a tissue temperature rise is the
goal of treatment. The use of cold, or cryotherapy, is most
effective in the acute stages of the healing process the
following injury when tissue temperature loss is the goal of
therapy. Cold applications can be continued into the
reconditioning stage of injury management. The term
hydrotherapy can be applied to any cryotherapy or
thermotherapy technique that uses water as the medium for
heat transfer [43].
Physiologic effects of heat
Local superficial heating (infrared heat) is recommended in
sub acute conditions for reducing pain and inflammation
through analgesic effects. Superficial heating produces
lower tissue temperatures at the site of the pathology
(injury) relative to the higher temperatures in the superficial
tissues, resulting in analgesia. During the later stages of
injury healing, a deeper heating effect is usually desirable;
it can be achieved by using the diathermies or ultrasound
[43].
Heat dilates blood vessels, causing the resting capillaries
(patent small blood vessels) to open up and increase
circulation. The skin is supplied with sympathetic
vasoconstrictor fibers that secrete norepinephrine at their
endings (especially evident in feet, hands, lips, nose, and
ears). At normal body temperature the sympathetic
vasoconstrictor nerves keep vascular anastomoses (blood
vessel junctions) almost totally closed, but when the
superficial tissue is heated, the number of sympathetic
impulses is greatly reduced so that the anastomoses dilate
and allow large quantities of warm blood to flow into the
venous plexuses (a group of veins). This promotes heat loss
from the body, which can increase blood flow about
twofold [43].
The hyperemia (increased blood flow) created by heat has a
beneficial effect on injuries. This is based on increases of
blood flow and pooling of blood during the metabolic
processes. Recent hematomas (blood clots) should never be
treated with heat until resolution of bleeding in completed
[43].
The rate of metabolism of tissues is dependent in part on
temperature. The metabolic rate has been shown to increase
approximately 13% for each 1 C increase in temperature. A
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similar decrease in metabolism has been demonstrated
when temperatures are lowered [43].
A primary effect of local heating is an increase in the local
metabolic rate with a resulting increase in the production of
metabolites and additional heat. These two factors lead to
an increased intravascular hydrostatic pressure, causing
arteriolar vasodilatation and increased capillary blood flow.
However, with increased hydrostatic pressure, there is a
tendency toward formation of edema, which may increase
the time required for rehabilitation of a particular injury.
Increased capillary blood flow is important with many
types of injury in which there is mild or moderate
inflammation, because it causes an increase in the supply of
oxygen, antibodies, leukocytes, and other necessary
nutrients and enzymes, along with an increased clearing of
metabolites. With higher heat intensities vasodilatation and
increased blood flow will spread to remote areas, causing
increased metabolism in the unheated area. This is known
as consensual heat vasodilatation and may be useful in
many conditions where local heating is contraindicated
[43].
The application of heat can produce an analgesic effect,
resulting in a reduction in the intensity of pain. The
analgesic effect is the most frequent indication for the use
of heat. Although the mechanisms under this phenomenon
are not well understood current thinking is that it is in some
way related to the gate control theory of pain modulation
[43].
Heat is applied in musculoskeletal and neuromuscular
disorders, such as sprains, strains, articular (joint-related)
problems, and muscle spasms, which all describe various
types of muscle pain [43].
Effects of cooling
The physiologic effects of cold are for the most part
opposite those of heat, the primary effect being a local
decrease in temperature. Local cooling is strongly indicated
in the acute stage of the healing process to decrease pain,
muscle spasm, and inflammation. Cold is also known to
reduce the metabolic rate, with a corresponding decrease in
production of metabolites and metabolic heat.
In acute injury there is increasing agreement that the use of
cold is the initial treatment for most conditions involving
strains, sprains, and contusions. It is most commonly used
immediately after injury to decrease pain and promote local
vasoconstriction thus controlling hemorrhage and edema
(swelling). It is also used in the acute phase of
inflammatory conditions such as bursitis, tenosynovitis, and
tendonitis, in which heat may cause additional pain and
swelling. Cold is also used to reduce pain and the reflex
muscle spasm and spastic conditions that accompany it. Its
analgesic effect is probably one of its greatest benefits. One
explanation of the analgesic effect is that cold decreases the
velocity of nerve conduction, although it does not entirely
eliminate it. It is also possible that cold bombards central
pain receptor areas with so many cold impulses that pain
impulses are lost through the gate control therapy of pain
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
modulation. With ice treatments, the patient usually reports
an Uncomfortable sensation of cold followed by burning,
then an aching sensation, and finally complete numbness
[43].
Cold does depress the excitability of free nerve endings and
peripheral oral nerve fibers, and this increases the pain
threshold. This is of great value in short-term treatment.
Cold applications can also enhance voluntary control in
spastic conditions, and in acute traumatic conditions they
may decrease painful spasms that result from local muscle
irritability. Reduction in muscle spasm relative to acute
athletic trauma has been observed by all active sports
therapists [43].
The initial reaction to cold is local vasoconstriction of all
smooth muscle by the central nervous system in order to
conserve heat. Localized vasoconstriction is responsible for
the decrease in the tendency toward formation and
accumulation of edema probably as a result of a decrease in
local hydrostatic pressure- There is also a decrease in the
amount of nutrients and phagocytes (cells that eliminate
debris) delivered to the area, thus reducing phagocyte
activity [43].
The following physiologic effects of cold have been
documented:
• Decreased local temperature, in some cases to a
considerable depth
• Decreased metabolism
• Vasoconstriction of arterioles and capillaries
• Decreased blood flow
• Decreased nerve conduction velocity
• Decreased delivery of leucocytes and phagocytes
• Decreased lymphatic and venous drainage
• Decreased muscle excitability
• Decreased muscle spindle depolarization
• Decreased viscosity of muscle
• Decreased formation and accumulation of edema
• Extreme anesthetic effects
The application of cold causes decreased cell permeability,
decreased cellular metabolism, and decreased accumulation
of edema and should be continued in 5 to 45 minute
applications for tip to 72 hours following initial trauma
[43].
Effects of tissue temperature change on circulation
Local application of heat or cold is indicated for thermal
physiologic effects. The main physiologic effect is on
superficial circulation because of the response of the
temperature receptors in the skin and the sympathetic
nervous system [43].
The circulatory apparatus is composed of two major vessel
types: nutritive arteries, capillaries, and veins; and vascular
structures for heating the skin. Two types of vascular
structures are the subcutaneous venous plexus, which holds
large quantities of blood that heat the surface of the skin
BB-40
and the arteriovenous anastomosis, which provides vascular
communication between arteries and venous plexuses. The
walls of the plexuses have strong muscular coats innervated
by sympathetic vasoconstrictor nerve fibers that secrete
norepinephrine. When constricted blood flow is reduced in
the venous plexus to almost nothing. When maximally
dilated, there is an extremely rapid flow of warm blood into
the plexuses. The arteriovenous anastomoses are found
principally in the volar or palmar surfaces of the hands and
feet, the lips, the nose, and the ears [43].
When cold is applied directly to the skin, the skin vessels
progressively constrict to a temperature of about 15 °C
(590 °F), at which point they reach their maximum
constriction. This constriction results primarily from
increased sensitivity of the vessels to nerve stimulation, but
it probably also results at least partly from a reflex that
passes to the cord and then back to the vessels. At
temperatures below l5 °C (59 °F) the vessels begin to
dilate. This dilation is caused by a direct local effect of the
cold on the vessels themselves, producing paralysis of the
contractile mechanism of the vessel wall or block of the
nerve impulses coming to the vessels. At temperatures
approaching 0 °C (32 °F), the skin vessels frequently reach
maximum vasodilatation. Vasodilatation associated with
intense cold plays a protective role in preventing freezing
of the exposed portions of the body, and it is commonly
referred to as hunting reaction [43].
Three types of sensory receptors are involved in the sub-
epithelial tissue: cold, warm, and pain. The pain receptors
are free nerve endings. Temperature and pain are
transmitted to the brain via the lateral spinothalamic tract.
The nerve fibers respond differently at different
temperatures. Above 45 °C (113 °F) cold receptors begin
to discharge again and pain receptors are stimulated. Nerve
fibers transmitting sensations of pain respond to the
extremes of temperature. Both warm and cold receptors
adapt rapidly to temperature change; the more rapid the
temperature change, the more rapid the receptor adaptation
[43].
General exposure to cold elicits cutaneous vasoconstriction,
shivering, piloerection, and an increase in epinephrine
secretion, so vascular contraction occurs. Simultaneously,
metabolism and heat production are increased to maintain
the body temperature [43].
Increased blood flow supplies additional oxygen to the
area, thus explaining the analgesic and relaxation effects on
muscle spasm. An increased proprioceptive reflex
mechanism may explain these effects. Receptor end organs
located in the muscle spindle are reflexly inhibited by heat
temporarily, while sudden cooling tends to excite the
receptor end organ [43].
Clinical use of the infrared modalities
Infrared energy can have a depth of penetration greater than
1 cm, thus the effects of the infrared modalities are
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
primarily superficial and directly affect the cutaneous blood
vessels and the cutaneous nerve receptors.
Absorption of infrared energy cutaneously increases and
decreases circulation subcutaneously in both the muscle
and fat layers. If the energy is absorbed cutaneously over a
long enough period of time to raise the temperature of the
circulating blood, the hypothalamus will reflexly increase
blood flow to the underlying tissue. Likewise, absorption of
cold cutaneously can decrease blood flow via a similar
mechanism in the area of treatment [43].
Thus if the primary treatment goal is a tissue temperature
increase with a corresponding increase in blood flow to the
deeper tissues, it is perhaps wiser to choose a modality,
such as diathermy or ultrasound that produces energy that
can penetrate the cutaneous tissues and be directly absorbed
by the deep tissues [43].
If the primary treatment goal is to reduce tissue temperature
and decrease blood flow to an injured area, it should be
clear that the superficial application of ice or cold is the
only modality capable of producing such a response [43].
Perhaps the most effective use of the infrared modalities
should be for the purpose of analgesia or reducing the
sensation of pain associated with injury. The infrared
modalities stimulate primarily the cutaneous nerve
receptors. Within the philosophy of an aggressive program
of rehabilitation, as is standard in most sports medicine
settings, the reduction of pain as a means of facilitating
therapeutic exercise is a common practice [43].
Cryotherapy techniques
Cryotherapy is the use of cold in the treatment of acute
trauma and sub acute injury and for the decrease of
discomfort following athletic reconditioning and
rehabilitation. Tools of cryotherapy include ice packs, cold
whirlpool, ice whirlpool, ice massage, commercial
chemical cold spray, and contrast baths. Application of
cryotherapy produces a three to four stage sensation. First
there is a sensation of cold followed by a stinging, then a
burning or aching feeling and finally numbness. Each stage
is related to the nerve endings as they temporarily cease to
function as a result of de creased blood flow [43].
Depth of penetration is dependent on the amount of cold
and the length of the treatment time because the body is
well-equipped to maintain skin and subcutaneous tissue
viability through the capillary bed by reflex vasodilatation
of up to 4 times normal blood flow.
The body has the ability to decrease blood flow to the body
segment that is supposedly losing too much body heat by
shunting the blood flow. Depth of penetration is also
related to intensity and duration of cold application and the
circulatory response to the body segment exposed. If the
person has normal circulatory responses, frostbite should
not be a concern. Even so, caution should be exercised
when applying intense cold directly to the skin. If deeper
penetration is desired, ice therapy is most effective using
ice towels, ice packs, ice massage, and ice whirlpools [43].
BB-41
Ice massage
Ice massage can be applied by the therapist or by the
person itself if the person can reach the area of application
to administer self-treatment. It is best for the first three
treatments to be administered by the therapist to give the
person the full benefit of the treatment. When positioning
the person’s body segment to be treated, it should be
relaxed and the he should be made comfortable.
Appropriate seating and positioning should be taken into
consideration with the application of ice. Administration
must be thorough to get the most out of the treatment. Ice
massage is perhaps best indicated in conditions in which
some type of stretching activity is to be used [43].
Treatment
• Athlete position. Sidelying, prone, supine,
hooklying, or sitting, depending on the area to be
treated.
• Self-treatment. Used when athletes can
comfortably reach the area to be treated by
themselves.
• Circular motion. Application of ice massage in a
circular pattern with each succeeding stroke
covering half the previous stroke.
• Longitudinal strokes. Application of ice massage
in a longitudinal motion with each stroke
overlapping half the previous stroke.
• Peripheral coverage. Ice should be applied for 15
to 20 minutes, consistent patterning of circular
and longitudinal strokes include the sequence
described in the clinical uses section.
Physiologic responses
• Cold progression proceeds through the four
stages: cold, sting ing, burning, and numbness.
• Reddening of the skin (erythema) occurs as a
result of blanching or lack of blood in the
capillary bed. A common example occurs when
one works outside in the cold without gloves or
appropriate footwear and returns inside to find
the toes beet-red. The body is attempting to pool
blood in the area to prevent further tempera ture
loss.
• Ice applications of 5 to 15 minutes and greater
than 10 C (50 F) will not stimulate the hunting
reaction and do not Stimulate the reflex
vasodilation that creates the bodys own
physically induced heat or increased blood flow.
Commercial (cold) hydrocollator packs
Cold hydrocoilator packs are indicated in any acute injury
to a muscle skeletal structure. Treatment includes:
• Athlete position. Side lying, prone, supine,
hookiying, or sitting, depending on the area to be
treated
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
• The patient must simply remain still during the
treatment to maintain appropriate positioning of
the cold pack.
• Cold pack must be molded onto the skirt
• The pack should be covered with a towel to limit
loss of cold.
• A timer should be set or time should otherwise be
noted.
• Treatment time should be 20 minutes.
Physiologic response:
• Cold progression proceeds through the four
stages.
• Erythema occurs.
1. Ice packs
Like cold hydrocollator packs, ice packs are indicated in
acute stages of in as well as for prevention of additional
swelling after exercise of the injured part. Treatment
includes:
• Athlete position. Position depends on the part to
be treated.
• The patient must simply remain still during
treatment.
• Pack must be placed on skin.
• Pack should be secured in place with toweling or
elastic bandage.
• Pack should be covered with towel to limit cold
loss.
• A timer should be set or time should otherwise be
noted.
• Treatment time should be 20 minutes.
Physiologic response:
• Cold progression proceeds through the four
stages.
• Erythema occurs.
2. Cold whirlpool
The cold whirlpool is indicated in acute and subacute
conditions in which exercise of the injured pan during a
cold treatment is desired.
Treatment includes:
• Temperature should be set at 5O to 6O °F.
• Body segment must be immersed.
• For total body immersion the water temperature
should be set at 65 to 80° F.
• Treatment tune should be 5 to 15 minutes.
Physiological responses
BB-42
 • Cold progression proceeds through the four
stages.
• Erythema occurs.
3. Cold spray
Cold sprays, such as Fluori-Methane or ethyl chloride, do
not provide adequate deep penetration, but they do provide
adjunctive therapy for acupressure techniques to reduce
muscle spasm. Physiologically this is accomplished by
stimulating the A fibers involved in the gate control theory.
The primary action of a cold spray is reduction of the pain
spasm sequence secondary to direct trauma. It will,
however, not reduce hemorrhage be cause it works on the
superficial nerve endings to reduce the spasm via the
stimulation of A fibers to reduce the so-called painful arc.
Precautions concerning the use of cold spray include
protecting the face of the patient from the fumes and
spraying the skin at an acute angle rather than at a
perpendicular angle. Cold spray is indicated when
stretching of an injured part is desired along with cold
treatment. Treatment includes:
• The area to be treated should be sprayed and then
stretched.
• Spasm should be reduced.
• Treatment should be distal to proximal.
• A quick jetstream spray or stroking motion
should be used.
• Coaling should be superficial, no frosting should
occur
• Cold sprays may be used in conjunction with
acupressure
• Treatment time should be set according to body
segment
Physiologic response
• Muscle spasm is reduced.
• Golgi tendon organ response is facilitated.
• Muscle spindle response is inhibited.
• Ligament and other musculoskeletal structures
may be stimulated.
4. Contrast bath
Contrast baths are used to treat subacute swelling, gravity-
dependent Contras swelling, and vasodilatation -
vasoconstriction response. Treatment includes:
• Hot and cold immersions are alternated.
• Treatment time should heat least 20 minutes.
Treatments should consist of five 1-minute cold
immersions and five 3 warm immersions.
Although the exact ratio of cold to hot treatment
is highly variable.
Physiologic response:
• Vasoconstriction and vasodilatation occur.
• There is a reduction of necrotic cells at the
cellular level.
• Edema is decreased.
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
Ice immersion
Ice buckets allow ease of application for the therapist.
Again, a wet area should be selected (where spilled water is
not a concern), with the patient positioned for comfort. The
immersion, like the contrast bath, should be maintained
until desired results ale reached. If cryokinetics are part of
the treatment, then the container should be large enough to
allow for the movement of the body segment. Ice
immersion is similar to cold whirlpool in that the body
segment may be subject to gravity-dependent positions
[43].
Cryoldnetics is a technique that combines the use of
various cryotherapy treatments with exercise. The goal of
cryokinetics is to numb the injured part to the point of
analgesia and then work toward achieving normal range of
motion through controlled exercises. The exercises are
continued until a sensation of pain returns, at which point
the injured part is iced again for several minutes, until it is
numb, and exercise continues. This sequence is repeated
four or five times. Cryokinetics is thought to inhibit painful
impulses, allowing the injured tissues to return to early
activity, while simultaneously stimulating circulation,
through exercise [43].
Thermotherapy techniques
Heat is still used as a universal treatment for pain and
discomfort. Much of the benefit is derived from the
treatment simply feeling good. However, in the early stages
following injury, heat causes increased capillary blood
pressure and increased cellular permeability; this results in
additional swelling or edema accumulation. No person with
edema should be treated with any heat modality until the
reasons for the edema are determined. It is in the best
interests of the therapist to use cryotherapy techniques or
contrast baths to reduce the edema prior to heat
applications. Superficial heat applications seem to feel
more comfortable for complaints of the neck, back, low
back, and pelvic areas and may be most appropriate for the
athlete who exhibits some allergic response to scold
applications. However, it must be remembered that the
tissues in these areas are absolutely no different from those
in the extremities. Thus, the same physiologic responses to
the use of heat or cold will be elicited all areas of the body
[43].
Figure 37. Whirlpool [43].
BB-43
Primary goals of thermotherapy include increased blood
flow and increased muscle temperature to stimulate
analgesia, increased nutrition to the cellular level, reduction
of edema, and removal of metabolites and other products of
the inflammatory process [43].
Hydrotherapy
Hydrotherapy is the use of water in the treatment of
disease. Hydrothermal therapy additionally uses its
temperature effects, as in hot baths, saunas, wraps, etc.
The recuperative and healing properties of hydrotherapy
are based on its mechanical and/or thermal effects. It
exploits the body's reaction to hot and cold stimuli, to the
protracted application of heat, to pressure exerted by the
water and to the sensation it gives. The nerves carry
impulses felt at the skin deeper into the body, where they
are instrumental in stimulating the immune system,
influencing the production of stress hormones, invigorating
the circulation and digestion, encouraging blood flow, and
lessening pain sensitivity. Generally, heat quiets and
soothes the body, slowing down the activity of internal
organs. Cold, in contrast, stimulates and invigorates,
increasing internal activity. If you are experiencing tense
muscles and anxiety from your stress, a hot shower or bath
is in order. If you are feeling tired and stressed out, you
might want to try taking a warm shower or bath followed
by a short, invigorating cold shower to help stimulate your
body and mind [43].
When you submerge yourself in a bath, a pool, or a
whirlpool, you experience a kind of weightlessness. Your
body is relieved from the constant pull of gravity. Water
also has a hydrostatic effect. It has a massage-like feeling
as the water gently kneads your body. Water, in motion,
stimulates touch receptors on the skin, boosting blood
circulation and releasing tight muscles [43].
Hydrotherapy and hydrothermal therapy are chiefly used to
tone up the body, to stimulate digestion, the circulation, and
the immune system, and to bring relief from pain.
Description of indications are given under individual
method used. Water seems to have special powers in
getting rid of stress and rejuvenating our body. It affects the
skin and muscles. It calms the lungs, heart, stomach, and
endocrine system by stimulating nerve reflexes on the
spinal cord [43].
Sauna and steam baths
Saunas and steam baths are similar in effect; the decision to
take one rather than the other will be guided by personal
preference. In a sauna the heat acts more quickly to
eliminate toxins through the skin, though some consider the
moist air of a steam bath to have a more satisfying effect on
the respiratory system. Saunas are deeply relaxing and are a
great way to melt away stress.
A sauna is an eliminative procedure; it stimulates blood
flow, increases the heart rate, has an immune-modulating
effect, promotes hormone production, encourages mucosal
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
secretions in the respiratory system, opens the airways,
reduces resistance to respiration, regulates the vegetative
system, relaxes, and can improve mental outlook. Children
can start to take saunas at two or three years of age [43].
Full and partial immersion baths
Various substances can be added to warm and rising
temperature baths. The following are the different kinds of
bath used:
Rising temperature hip bath.
This is taken in a tub filled with a hand's breadth of tepid
water. Hot water is then gradually added until the level
reaches the navel. The final temperature should be 103-
104'F. Following this procedure, the patient is wrapped
warm and proceeds to bed. It should last 15-30 minutes, not
more than three times per week [43].
Cold footbath.
The feet are placed into a footbath filled to calf depth with
cold water. Stop when a cold stimulus is felt or when the
water is no longer perceived as being particularly cold.
Stroke off excess water, dress, and walk or run until dry. A
special form of this treatment is "walking in water," which
involves walking stork-like on a non-slip mat placed under
the water. This type of treatment is best avoided by people
who suffer from cold feet, very high blood pressure, an
irritable bladder, urinary tract infection, diabetes, or
vascular occlusion [43].
Rising temperature footbath, warm footbath.
The feet are immersed in a footbath filled with water at
body temperature. Hot water is gradually added to give a
final temperature of 103-104'F. In warm foot baths water of
this temperature is added straight away. Keep warm
afterwards. The procedure should last 10-15 minutes and
can be done daily. Best avoided by people with varicose
veins, lymphostasis, or edema [43].
Cold arm bath.
A basin is filled with cold water until it reaches a depth
several inches above the immersed elbow. If the treatment
becomes intolerable, stop and repeat as desired. Good of
headaches and sleeplessness. Best avoided by people with
heart or circulatory problems [43].
Rising temperature arm bath.
In principle, this is the same as the rising temperature foot
bath. It should be followed by a cold arm douche, then by
half an hour's rest. Used for the treatment of bronchitis,
asthma, incipient respiratory infection, circulatory
problems, angina pectoris [43].
Sitz bath.
This is generally taken in a hip bath as a cold, rising
temperature, or warm sitz bath. Prior to a sitz bath, warm
BB-44
the feet, e.g. through a warm foot bath. Parts of the body
not immersed in water should be covered. Cold sitz bath for
hemorrhoids or inflammation of the anus; warm or rising
temperature sitz bath for difficulty in voiding the bladder,
an irritable bladder, inflammation or infection of the
prostate, preparation for pregnancy. Do not use warm or
rising temperature sitz baths for hemorrhoids. A wrap is
primarily used as a supportive measure for treating fever
and local inflammation. The person reiving treatment
should first adopt a relaxed position. Then a linen cloth is
moistened with cold water (warm water for respiratory
diseases), well wrung out, and then wrapped tightly around
the appropriate part of the body, but not so tightly as to
cause constriction. The moist linen cloth is in turn wrapped
with a dry cotton or linen cloth. The patient is then usually
wrapped in a blanket or another cloth, and should rest for
45-60 minutes or, if the intention is to induce sweating, for
up to three hours. If the wrap is not felt to be warm after a
quarter of an hour, heat should be applied in the form of a
hot water bottle or by giving warm tea. The wrap should be
removed immediately if the person complains of feeling
unwell [43].
Warm packs.
A wrapping cloth is soaked in a hot infusion or decoction
of herbs, then wrung out and applied to the patient's body.
Alternatively, the wrap may receive a coating of hot mud
mustard flour, or fango. As a further alternative, hayseed
may be placed in a sack and steamed. Indications; painful
chronic diseases such as arthrosis, renal disease, or cystitis,
and for stimulating blood flow. Always check that the
temperature is tolerable before applying a wrap [43].
Cold packs.
Cooled cataplasm is spread onto the wrapping cloth and
placed on the part of the body. Crushed ice in a plastic bag
may also be repeatedly applied for one minute, then
removed for four. Used for the treatment of various
inflammatory arthropathies, sprains and strains, pleurisy.
Ice packs can also be used for headaches [43].
Different forms of preparing a herbal bath
• Simmer 1/2 cup of herbs in 1 quart of water in a
covered pot for fifteen minutes. While the herbs
are simmering, take a short shower to cleanse
your body, then fill the tub with hot or warm
water. Strain the liquid from the decoction into
the bath water, and wrap the herbs in a
washcloth. Soak in the tub for at least twenty
minutes, using the "herbal washcloth" to rub over
your body. -
• Add 1/2 cup of herbs to running bath water,
preferably hot. You might want to cover the drain
with a thin mesh screen to prevent the herbs from
clogging the pipes. Soak in the tub for twenty to
thirty minutes.
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
• Fill a thin cloth bag with 1/2 cup of herbs, either
placing it in the bath water or tying it to the
spigot so that the hot water runs through it as it
fills the tub. Again, soak for twenty to thirty
minutes.
Certain herbs are quite effective for creating soothing
baths. Combine a handful each of valerian, lavender,
linden, chamomile, hops, and burdock root, and add it to
your bath according to one of the preceding methods. Soak
for thirty minutes in the tub. Another soothing herbal bath
calls for a handful each of hops, linden, valerian,
chamomile, yarrow, and passionflower. Prepare this bath
according to one of the preceding methods, or simmer the
herbs in a quart of water, then drink ½ cup of the liquid
(with lemon and honey added, if you wish) and pour the
rest in the tub. While soaking in an herbal bath, you can
read, meditate, listen to peaceful music, or just sit quietly,
concentrating on relaxing yourself [43].
Importance of drinking sufficient water
It is very important that we drink sufficient amount of
water in a day to make up for the water lost. The benefits of
drinking water are widely recognized. Drinking pure, fresh
water is essential to our health and well-being. Steps for an
effective hydrotherapy:
• For overall tension reduction, use a neutral bath
(temperature between 92 to 94 °F) that is close to
the skin temperature.
• Use water temperature between 102 to 106 °F for
loosening tight, tense muscles and reducing the
pain of stress-related conditions such as
backache. (Using temperatures higher than 106
degrees is not recommended as it can raise your
body temperature very fast, inducing an artificial
fever.)
• Take a cold shower after you step out of the bath.
This brings and immediate rush of blood through
your system, as well as a rush of energy. (Try
alternating cold and hot shower to get a similar
effect. 3 minutes of hot water followed by 30
seconds of cold water and the 3 minutes of hot
water, etc.) Stay in the bath no more than 15 to
20 minutes. If you have high blood pressure or
cardiovascular problems, don't stay long enough
to raise your body temperature.
Paraffin baths
Paraffin bath is a simple and efficient, though somewhat
messy, technique for applying a fairly high degree of
localized heat. Paraffin treatments provide 6 times the
amount of heat available in water because the mineral oil in
the paraffin lowers the melting point of the paraffin.
The risk of a burn with paraffin is substantial. The sports
therapist should weigh heavily the considerations between
a paraffin bath and warm whirlpool bath in the athletic
BB-45
setting. The majority of paraffin baths are used for chronic
arthritis patients’ hands and feet. If the patient has a chronic
hand or foot problem, the use of paraffin instead of water
usually gives longer lasting pain relief [43].
Physiologic responses
• There is an increase in tissue temperature.
• Pain relief occurs.
• Thermal hyperthermia occurs.
Infrared lamps
When talking about infrared modalities, the therapist most
typically thinks of the infrared lamp. The biggest advantage
of an infrared lamp is the superficial tissue temperature rise
and the fact that the unit does not touch the patient.
However, radiant heat is seldom used because it is limited
in depth of skin penetration to less than 1 mm. It is
recommended that a warm moist towel be placed over the
body segment to be treated to enhance the heating effects.
Dry towels should cover the remainder of the body not
being treated. These will allow a greater blood/tissue
exchange by trapping the heat build-up in the moist towel
and reducing the stagnant air over the body segment [43].
Infrared generators may be divided into two categories:
luminous and nonluminous. Nonluminous generators
consist of a spiral coil of resistant metal wire wound around
a cone shaped piece of nonconducting material. The
resistance of the wire to the electric flow produces heat and
a dull red glow. A properly shaped reflector then radiates
the heat to the body. All incandescent bodies and tungsten
and carbon filament lamps are in the category of luminous
generators [43].
Physiologic response
• A superficial rise in tissue temperature occurs.
• There is some decrease in pain.
• Moisture and sweat appear on the skin surface.
Fluid therapy
Fluid therapy is a unique, multifunctional physical
medicine modality. The fluidotherapy unit is a dry heat
modality that uses a suspended air stream which has the
properties of a liquid. Its therapeutic effectiveness in
rehabilitation and healing is based on its ability to
simultaneously apply heat, massage, sensory stimulation
for desensitization, levitation, and pressure oscillations.
Unlike water, the dry, natural medium does not irritate the
skin or produce thermal shocks. This allows for much
higher treatment temperatures than with aqueous or
paraffin heat transfer. The pressure oscillations may
actually minimize edema, even at very high treatment
temperatures. Outstanding clinical success has been
reported in treatment of pain, range of motion, wounds,
acute injuries, swelling, and blood flow insufficiency.
Fluidotherapy treatment of the hand at 115 °F (46.2 °C)
results in a sixfold increase in blood flow and a fourfold
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
increase in metabolic rates in a normal adult. These
properties will increase blood flow sedate, decrease blood
pressure, and promote healing by accelerating bio chemical
reactions [43].
Counter irritation, through mechanoreceptor and
thermoreceptor stimulation, reduces pain sensitivity, thus
permitting high temperatures with out painful heat
sensations. Pronounced hyperthermia accelerates the
chemical metabolic processes and stimulates the normal
healing process. The high temperatures enhance tissue
elasticity and reduce tissue viscosity, which improves
musculoskeletal mobility. Vascular responses are
stimulated as a result of the long-lasting hyperthermia and
pressure fluctuations, resulting in increased blood flow to
the injured area. Treatment includes:
• The patient must be positioned for comfort.
• The patient should place the body segment to be
treated (hand or foot) in the fluidotherapy unit.
• Protective toweling must be placed at the umt
interface arid body segment.
• Treatment time should be 15 to 20 minutes.
Physiologic responses
• Tissue temperature increases.
• Pain relief occurs.
• Thermal hyperthermia occurs.
Ultrasound
Ultrasound has become an accepted modality in the
treatment of injuries during the last three to four decades.
Its use continues to become more judicious as we learn
more about the healing process and the effect of ultrasound
on that process.
Ultrasound is truly a therapeutic modality that aids
therapists in their attempts to return athletes to pre-injury
status. Before being ad ministered, however, it must be
preceded by an orthopedic evaluation to determine the
tissues involved the degree of injury, and the status of the
healing process [43].
Ultrasound must be respected for the significant effects it
produces on a variety of tissues and for its depth of
penetration. In the hands of individuals who do not
understand its effects and those who would ad minister it
before an appropriate musculoskeletal examination, it is a
modality that could be more of a liability than a benefit
[43].
Ultrasound falls under the classification of the acoustic
spectrum rather than the electromagnetic spectrum. Sound
waves that are at a higher frequency than are detectable by
the human ear are termed ultrasound. Therefore frequencies
above 16,000 to 20000 Hz are defined as ultrasound.
Standard therapeutic units used on the musculoskeletal
system operate at a frequency between 800000 and
1,000,000 Hz. The major purpose for using ultrasound is in
the treatment of soft tissue. The propagation of ultrasonic
BB-46
energy in biologic tissue depends on the absorption the extensibility of tight capsular tissue and in the mobility
characteristics of the tissue, as well as on the density of the of mature scar tissue have been proven with ultrasound and
tissue [43]. exercise [43].

1. Anatomy of the equipment Ultrasound produces the desirable therapeutic effects of

Ultrasound machines are not as mechanically and
electrically complex as many other therapeutic modalities.
A high frequency generator provides electricity via a
coaxial cable to the hot electrode in the transducer. The
transducer contains a crystal made of quartz or a synthetic
ceramic. The sound head also includes an insulator and a
metal front plate that serves as the surface of the applicator.
The unit also contains a timer directly inked to the on-off
switch and either a digital display or meter that shows the
output of the total number of watts and the watts per square
centimeter of the surface of the sound head
2. Effects
Physiologic effects that occur because of heating of tissues
are referred to as thermal. Many of the effects of ultrasound
are attributed to heat. It is generally accepted that heat
produces the following results:
any deep heat modality. The effect of ultrasound that may
be the most distinguish able is its ability to selectively
increase temperature in local, well circum scribed areas
[43].
3. Under water
Ultrasound can be used effectively under water to treat
irregular surfaces such as a hand. The sound head need not
be in contact with the body part and is moved in a circular
fashion. The applicator should be approximately ½ inch
from the body part and the intensity setting is the same as
for regular application. Bubble formation sometimes occurs
over the head as a result of gaseous separation and needs to
be wiped of by the person administering the treatment. This
degassing process is done by simply rubbing the bubbles
off with the fingers and proceeding with the treatment [43].
4. Pulsed ultrasound

• Increases the extensibility of collagen tissue The theory behind the development and use of pulsed
• Decreases joint stiffness ultrasound is that the mechanical effects can be produced
• Reduces pain without thermal effects. The pulsed beams, as compared to
• Reduces muscle spasm continuous beams, allow for a rest period for cooling
• Assists in mobilizing inflammatory infiltrates, purposes [43].
edema, and exudates
• Increases blood flow 5. Simultaneous ultrasound and electrical stimulation
• Increases local metabolism
Machines are available to incorporate the use of ultrasound
with either low-voltage alternating current or high-voltage
Effects at the cellular level that are the result of the
direct current. In these units, the transducer becomes an
vibratory motion are referred to as mechanical effects.
Acceleration in the rate of diffusion across membranes has, active electrode that causes muscle stimulation as it is
passed over an area- This technique is used most
however, been shown to be a result of mechanical
commonly on spasmodic areas that would benefit from
vibration. This results in increased blood flow and
both modalities [43].
consequently absorption of the by-products of the healing
process, thus facilitating that process. This in itself is
significant to consider when an injury is in an acute or 6. Coupling agents
subacute phase [43].
Because sound waves at the frequencies emanating from
When energy is added to the body in the form of sound the machine do not readily travel through au, specific
coupling mediums are necessary. The coupling medium
waves, it is absorbed transmitted, reflected, or refracted.
must have good lubricating qualities so that the applicator
Tissues of high water content have a low rate of absorption
can glide against the skin on even very hairy
(thereby a high rate of penetration) while tissues of high
protein content have a high rate of absorption. Fat has a
relatively low absorption rate and muscle absorbs
considerably more. Bone that is rather superficial absorbs
more ultrasonic energy than any of the other tissues. This is
thought to be because of the high protein content and
density of bone compared to other tissue. Peripheral nerve
absorbs at a rate approximately twice that of muscle. It has
been concluded that soft tissue in close proximity to bone
receives more of the effects of ultrasound because of a
rebound phenomenon. Therefore, joint structures such as
the periosteum, capsule, tendon, and extra capsular
ligament are significantly affected by ultrasound treatment.
It has been demonstrated that ultrasound raises the
Figure 38. Ultrasound machine [43].
temperature in the collagen tissues of tendon. Increases in

July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez BB-47

Figure 39. Ultrasound doppler machine [43]
Figure 40. Abdominal ultrasound machine [43]
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
individuals with out significant friction. There are many
commercial gels on the market to serve as this medium.
Studies have been done that showed no significant
difference between the common commercial gels, mineral
oil, and de gassed water [43].
Interferential therapy
The basic principle of Interferential Therapy is to utilizes
the strong physiological effects of low frequency electrical
stimulation of muscle and nerve tissues without the
associated painful and somewhat unpleasant side effects of
such stimulation. To produce low frequency effects at
sufficient intensity at depth, most patients experience
considerable discomfort in the superficial tissues. This is
due to the resistance (impedance) of the skin being
inversely proportional to the frequency of the stimulation.
The skin impedance at 50Hz is approximately 3200W with
4000Hz it is reduced to approximately 40W. The result of
applying this latter frequency is that it will pass more easily
through the skin, requiring less electrical energy input to
reach the deeper tissues & giving rise to less discomfort
[43].
Interferential therapy utilizes two of these medium
frequency currents, passed through the tissues
simultaneously, where they are set up so that their paths
cross. This interference gives rise to an interference or beat
frequency which has the characteristics of low frequency
stimulation [43].
The exact frequency of the resultant beat frequency can be
controlled by the input frequencies. By careful
manipulation of the input currents it is possible to achieve
any beat frequency that you might wish to use clinically.
Modern machines usually offer frequencies of 1-150Hz,
though some offer a choice of up to 250Hz or more.
The use of 2 pole I/F stimulation, where there is clearly no
interference within the body, it is made possible by
electronic manipulation of the currents - the interference
occurs within the machine. The magnitude of the low
frequency interference current is approximately equivalent
to the sum of the input amplitudes [43].
1. Physiological effects:
Excitable tissues can be stimulated by low frequency
alternating currents. Although to some extent, all tissues in
this category will be affected by a broad range of
stimulations, it is thought (Savage 1984) that different
tissues will have an optimal stimulation band, which can be
estimated by the conduction velocity of the tissue, its
latency and refractory period. These are detailed below:
• Sympathetic Nerve 1-5Hz.
• Parasympathetic Nerve 10-150Hz.
• Motor Nerve 10-50Hz.
• Sensory Nerve 90-100Hz.
BB-48
 • Nociceptive fibers 90-150Hz (130Hz
specific).
• Smooth Muscle 0-10Hz.
The clinical application of I/F therapy can be based
logically on this data together with knowledge of
physiological behavior of stimulated tissue. Selection of a
wide treatment band can be considered less efficient than a
smaller selective band in that by treating with a frequency
range of say 1-100Hz, the appropriate treatment
frequencies can be covered, but only for a relatively small
percentage of the total treatment time. Additionally, some
parts of the range might be counterproductive for the
primary aims of the treatment [43].
They are 4 main clinical applications for which I/F appears
to be used:
• Pain relief.
• Muscle stimulation.
• Increased blood flow.
• Reduction of oedema.
In addition, claims are made for its role in stimulating
healing and repair.
As I/F acts primarily on the excitable tissues, the strongest
effects are likely to be those which are a direct result of
such stimulation (i.e. pain relief and muscle stimulation).
The other effects are more likely to be secondary
consequences of these [43].
2. Pain relief:
Electrical stimulation for pain relief has widespread clinical
use, thought the direct research evidence for the use of I/F
in this role is limited. Logically one could use the higher
frequencies (90-150Hz) to stimulate the pain gate
mechanisms & thereby mask the pain symptoms.
Alternatively, stimulation with lower frequencies (1-5Hz)
can be used to activate the opoid mechanisms, again
providing a degree of relief. These two different modes of
action can be explained physiologically & will have
different latent periods and varying duration of effect. It
remains possible that relief of pain may be achieved by
stimulation of the reticular formation at frequencies of 10-
25Hz or by blocking C fiber transmission at >50Hz [43].
3. Muscle stimulation:
Stimulation of the motor nerves can be achieved with a
wide range of frequencies. Clearly, stimulation at low
frequency will result in a series of twitches, whist
stimulation at 50Hz will result in a tetanic contraction. The
choice of treatment parameters will depend on the desired
effect, but to combine muscle stimulation with an increase
in blood flow and a possible reduction in oedema, there is
some logic in selecting a range which does not involve
strong sustained tetanic contraction and a sweep of 10-
25Hz is often used [43].
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
There is no primary nervous control of oedema
reabsorption and the direct electrical stimulation of blood
flow is limited in its effectiveness. It is suggested therefore
that in order to achieve these effects, suitable combinations
of muscle stimulation can be made [43].
4. Treatment:
Electrode positioning should ensure adequate coverage of
the area for stimulation. In some circumstances, a bipolar
method is preferable if a longitudinal zone requires
stimulation rather than an isolated tissue area. Placement of
the electrodes should be such that a crossover effect is
achieved in the desired area. If the electrodes are not placed
so that a crossover is achieved, the physiological effects of
I/F can not be achieved [43].
Nerves will accommodate to a constant signal and a sweep
(or gradually changing frequency) is often used to
overcome this problem (as well as generating a range of
effects). The sweep (range) should be appropriate to the
desired physiological effects, though again it is suggested
that an excessive range may minimize the clinical effect
[43].
The mode of delivery of the selected sweep varies with
machines. The most common application is the 6 second
rise and fall between the pre-set frequencies. For example,
if a 10 - 25Hz range has been selected, the machine will
deliver a changing frequency, starting at 10Hz, rising to
25Hz over a 6 second period. Once this upper limit has
been achieved, the frequency will once again fall, over a 6
second period to its starting point at 10Hz. This pattern is
repeated throughout the treatment session [43].
Other patterns of sweep can be produced on many
machines as illustrated:
Treatment times vary widely according to the usual clinical
parameters of acute/chronic conditions and the type of
physiological effect desired. In acute conditions, shorter
treatment times of 5-10 minutes may be sufficient to
achieve the effect. In other circumstances, it may be
necessary to stimulate the tissues for 20-30 minutes. It is
suggested that short treatment times are initially adopted
especially with the acute case in case of symptom
exacerbation. These can be progressed if the aim has not
been achieved and no untoward side effects have been
produced. There is no research evidence to support the
continuous progression of a treatment dose in order to
increase or maintain its effect [43].
INTENSIVE CARE UNIT
Although many promising objective methods (measuring
systems) are available, there are no truly validated
instruments for monitoring intensive care unit (ICU)
sedation. Auditory evoked potentials can be used only for
research in patients with a deep level of sedation. Other
measuring systems require further development and
validation to be useful in the ICU. Continuing research will
provide an objective system to improve the monitoring and
BB-49
controlling of this essential treatment for ICU patients.
Subjective methods (scoring systems) that are based on
clinical observation have proven their usefulness in guiding
sedative therapy. The Glasgow Coma Score modified by
Cook and Palma (GCSC) achieves good face validity and
reliability, which assures its clinical utility for routine
practice and research. Other scales, in particular the
Ramsay Scale, can be recommended preferably for clinical
use. An accurate use of available instruments can improve
the sedative treatment that we deliver to our patients [35].
10. http://imaginis . com / endoscopy/
11. http:// my. webmd. com/ hw/ health_guide_atoz/
Web MD Health
12. http:// oac.med.jh mi.edu/res_phys /E ncyclopedia/
Body Plethysmography
13. http:// umjmh .org/ Health Library/ Respiratory/
Incentive Spirometer

CONCLUSIONS 14. http://users.rcn.com /jkimball.ma.ultranet/

The Human Eye. 13 June 2004
We had the opportunity to increase our knowledge about
the role of fluids in all different system of the human body 15. http://www4 .tpgi.com.au/ users/ amc gann/body/
and what instruments were used to measure it. Now we can The Nervous System. 14 Jun 2004
mention instruments for measuring some fluids of the
human body easily. For example, blood pressure, with the 16. http://www .aafp.org/afp/ 20020915 /991. html
sphygmomanometer and the Schirmer strip, which American Family Physician
measures the quantity of total tear secretion. Also, we learn
about how system in human body function and it parts. 17 .http://www.agingeye.net/dryeyes/dryeeyeseyeexam.pp
This is good for us because now we understand better how Agind Eye Times
the human body function and we can prevent sickness or
just now what the doctor is doing when he is taking our 18. http://www.cfdrc.com/applications/biomedical/pumps.
pressure. After study all this we will check our self Blood Pumps
frequently to see how our system are working.
19. http://www. cncmagazine. com/v6i22/v6i22i-.htm.
ACKNOWLEDGEMENTS CNC Machine Magazine

This study was aided in part by the teachings of Dr. Megh 20. http://www .clevelandclinic org/ health/ health-
R. Goyal, University of Puerto Rico at Mayaguez. How To Use An Incentive Spirometer

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July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez BB-50
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Hand Held Applanation Tonometer with Prism
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Applanation Tanometer
41. http://www.v eatchinstruments .com/ perkins.htm
Clement Clarke Perkins MK2 Applanation Tonometer
42 .http://www .vitalograph.com /default.html?site_files/
Main Frame
43 Goyal, M.R. 2001, First Congress on Biofluids at
UPR-RUM.
GLOSSARY
Ablution- Act of washing or bathing.
Absorption- Energy that stimulates a particular tissue to
perform its normal function.
Absorption- The movement of nutrients and other
substances through the wall of the digestive tract and into
the blood.
Accommodation- Adaptation by the sensory receptors to
various stimuli over an extended period of time.
Acoustic-spectrum- The range of frequencies and
wavelengths of sound waves.
Action potential- A recorded change in electrical potential
between the inside and outside of a nerve cell, resulting in
muscular contraction.
Active electrode- Electrode at which greatest current
density occurs.
Adrenal cortex- The outer region of each adrenal gland;
secretes steroid hormones.
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
Adrenal glands- Paired endocrine glands, one located just
superior to each kidney; secretes
Afferent- Conduction of a nerve impulse toward an organ.
Afferent- Leading toward some point of reference.
Compare with efferent.
Alveolus- An air sac of the lung through which the gas
exchange with the blood takes place.
Amplitude- The intensity of current flow as indicated by
the height of the waveform from baseline.
Analgesia- Loss of sensibility to pain.
Anesthesia- Loss of sensation.
Anode- Positively charged electrode in a direct cur rent
system.
Anus: The distal end and outlet of the digestive tract.
Aorta. The largest and main systemic artery of the body;
arises from the left ventricle and branches to distribute
blood to all parts of the body except the lungs.
Aortic valve: Outlet valve from left ventricle to aorta.
Applicator- The electrode used to transfer energy in
microwave diathermy.
Arrhythmia: An alteration in rhythm of the heartbeat
either in time or force.
Artery: A thick walled blood vessel that carries away from
heart chamber and forward the body organs. Compared
with veins.
Atherosclerosis: A form of arteriosclerosis, is the
reduction in blood flow through the arteries caused by
greasy deposits called plaque that form on the insides of
arteries and partially restrict the flow of blood.
Atonic- Without tone.
Atrioventicular valve: A valve between each atrium and
its ventricle that prevents back flow of blood. The right
Atrioventricular valve is the tricuspid valve; the left
atrioventricular valve is the mitral valve.
Atrioventricular node: Mass of specialized cardiac tissues
that receive and impulse from sinoatrial node (peacemaker)
and conducts it to the ventricles.
Atrium: An anatomical cavity or passage; especially a
main chamber of the heart into which blood returns from
circulation.
Bile: The fluid secreted by the liver; emulsifies fats.
BB-51
Blood pressure: The force exerted by blood against the
inner walls of the blood vessel.
Blood: A fluid, circulating connective tissue that transport
nutrients and others materials through the body.
Bowman’s capsule: Doubled wall sac of cells that
surrounds the glomerulus of each nephron.
Brachial: relating to the arm or a comparable process.
Brain stem: The part of the brain that includes the
medulla, pons, midbrain, thalamus and hypothalamus.
Brain: A concentration of nervous tissue that control
neural function. Enlarge portion of the central nervous
system.
Bronchiole: Air duct in the lung that branches from a
bronchus; divides to form air sacs Alveoli).
Bronchus: One of the branches of the trachea and its
immediate branches within the lung.
Bundle of his: A small band of cardiac muscle fibers
transmitting the waves of depolarization from the atria to
the ventricles during cardiac contraction.
Cable electrodes- An inductance type electrode in which
the electrodes are coiled around a body part creating an
electromagnetic field.
Cannula: A small tube for insertion into a body cavity or
blood vessel.
Capillaries: Microscope blood vessels in the tissues the
permit exchange of materials between cells and blood.
Cardiac arrest: Standstill of the heart, its action and
diseases.
Cardiac cycle: One complete heart beat.
Cardiac output: The volume of blood pumped by the heart
per unit of time.
Cardiac: Pertaining to the heart.
Cardiology: The study of the heart, its action and diseases.
Cardiovascular disease: Diseases of the heart or blood
vessels.
Carpal tunnel syndrome: A painful and disabling disorder
characterized by inflammation and swelling in the tendons
that run through the narrow carpal tunnel in the wrist, and
one of the most common of repetitive motion injuries.
Cathode- Negatively charged electrode in a direct current
system.
Central Nervous System (CNS): The brain and spinal
cord.
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
Cerebellum: A convoluted subdivision of the brain
concerned with the coordination of muscular movements,
muscle tone, and balance.
Cerebrospinal Fluid (CFS): The fluid that bathes the
central nervous system.
Cerebrum: Large, convoluted subdivision of the brain; it
functions as the center for learning, voluntary movement,
and interpretation of sensation.
Circuit- The path of current from a generating source
through the various components back to the generating
source.
Circulatory system: The body system that functions in
internal transport and protects the body from disease.
Clitoris: A small, erectile structure at the anterior part of
the vulva in females; homologous to the male penis.
Coaxial cable- Heavy, well-insulated electrical wire.
Cochlea: The structure of the inner ear that contains the
auditory receptors (organ of Corti).
Cold-induced vasodilatation- Vasodilatation following
cold application.
Collagen tissue- Fibrous insoluble protein found in
connective tissue, bone, ligaments, and cartilage.
Collecting duct: A duct in the kidney that receives filtrate
from several nephrones and conducts it to the renal pelvis.
Colloid- The fluid suspension of the body’s intercellular
fluid.
Colon: Portion of the large intestine between the cecum
and the rectum.
Condenser electrodes- An electrical current is con ducted
back and forth between the two electrodes. Highest
concentration is under the electrodes, which may be pads or
space plates. Highest concentration is also in fat tissue
Conduction- Heat loss or gain through direct contact.
Cone: One of the conical photoreceptive cells of the retina
that is particularly sensitive to bright light and, by
distinguishing light of various wavelengths, mediates color
vision. Compare with rod.
Congestion- Presence of an abnormal amount of blood in
the vessels as a result of an increase in blood flow or
obstructed venous return.
Consensual heat vasodilatation- Increased blood flow that
spreads to a remote area of the body as a result of localized
heating.
BB-52
Contraindication- Special symptom or circumstance that
renders the use of a remedy or procedure in advisable.
Contrast bath- Hot (106° F) and cold (50° F) treatments in
a combined sequence to stimulate superficial capillary
vasodilatation or vasoconstriction.
Convection- Heat loss or gain through the movement of air
or water molecules across the skin.
Cornea: Transparent covering of the eye.
Coronary artery and sinus: Vessels carrying blood to and
from the walls of the heart itself.
Corpus collosum: A large bundle of nerve fiber
interconnecting the two cerebral hemispheres.
Corpus luteum: The temporary endocrine tissue in the
ovary that develops from the ruptured follicle after
ovulation.
Cortical: Relating to, or consisting of the cortex.
Coupling agent- A substance used as a medium for the
transfer of sound waves.
Cranial nerves: Ten to twelve pairs of nerves that emerge
directly from the brain.
Cranium: The body framework that protects the brain.
Cryokinetics- The use of cold and exercise in the treatment
of pathology or disease.
Cryotherapy- The use of cold in the treatment of
pathology or disease.
Crystal- The part of the ultrasound head that vibrates and
changes shape.
Dendrite: A branch of a neuron that receives and conducts
nerve impulses toward the cell body.
Depolarization- Process or act of neutralizing the cell
membrane’s resting potential.
Diastole: Phase of the cardiac cycle in which the heart is
relaxed.
Diastolic: Of or pertaining to the diastole.
Diathermy- The application of high-frequency electrical
energy that is used to generate heat in body tissues as a
result of the resistance of the tissue to the passage of
energy.
Diffusion: Net movement of particles from region of
higher concentration to a region of lower concentration,
resulting from random motion.
Digestion: The breakdown of food into smaller molecules.
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
Direct current- Galvanic current that always flows in the
same direction and may flow in either a positive or a
negative direction.
Distal convoluted tube: The part of the renal tubule that
extends from the loop of Henle to the collecting duct.
Douche- A current of water directed against the skin
surface (e.g., scotch douche alternating hot and cold water).
Duodenum: The portion of the small intestine into which
the contents of the stomach first enter.
ECG: Abbreviation for electrocardiogram.
Echocardiogram: An ultrasonic record of the dimension
and movement of the hearts and his valves.
Edema- Excessive fluid in cells.
EEG: Abbreviation for electroencephalogram.
Efferent: Leading away from point of reference.
Ejaculation: A sudden expulsion, as in the ejection of
semen from the penis.
Electrical field- A technique of heating the tissues in
shortwave diathermy in which the patient is part of the
electrical circuit.
Electrical potential- The difference between charged
particles at a higher and lower potential.
Electrical stimulation- The use of four or more electrodes.
AA’ and BB’ arranged so the path of electric current A to
A’ is crossed by the path of the electric current B to B’.
Electrocardiogram: A record of the electric activity of the
heart.
Electrocardiograph: An instrument used for the
measurement of the electrical activity of the heart.
Electroencephalograph: An instrument for measuring and
recording electrical activities from the brain (brain waves).
Electromagnetic spectrum- The range of frequencies and
wavelengths associated with radiant energy.
Electromyography- The pick-up and amplification of
electrical signals generated by the muscle as it contracts.
Electrostatic or condenser field- The patient is placed
between electrodes and becomes a part of a series circuit.
Elimination: Ejection of undigested food from the body.
Endocrine gland: Gland that secretes hormones directly
into the blood or tissue fluid instead of into a duct.
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Endocrine system: Body system that helps regulate
metabolic activities; consists of ductless glands and tissues
that secretes hormones
Endorphins- Endogenous opiates whose actions have
analgesic properties. They are neurophor mones and not
neurotransrnitters (i.e., β-endor- phins).
Enkephalin- Neurotransmitter proteins that are pain-
relieving molecules. They block the passage of noxious
stimuli by servicing descending neurons to counter
ascending signals. They inhibit the release of substance P
and are produced by enkephalinergic neurons.
Enkephalinergic neurons- Neurons with short axons that
release enkephalin. They act as interneUrofls (internuncial
neurons) and are found in the substantia gelatinosa, nucleus
raphae magnus, and periaqueductal gray matter.
Enzyme: An organic catalyst that accelerates a specific
chemical reaction by lowering the activation energy
required for the reaction.
Epididymis: A coiled tube that receives sperm from the
testis and conveys it to the vas deferent.
Epiglottis: A thin, flexible structure that guards the
entrance to the larynx, preventing food from entering the
airway during swallowing.
Epinephrine: Hormone produced by the adrenal gland.
Eustachian tube: The auditory tube passing between the
middle ear cavity and the pharynx; permits the equalization
of pressure on the tympanic membrane.
Excretion: The discharge from the body from a waste
product of metabolism (Do not confuse with the
elimination of undigested food materials).
Exocrine gland: Gland that excretes its product through a
duct that opens onto a free surface.
Expiratory reserve volume: The volume capable of being
expired at the end-expiratory level of a quiet expiration.
External respiration: Movement of gases in and out of
lungs.
Fallopian tube: Tube that carries ova from the ovary to the
utter.
Fluidotherapy- A modality of dry heat using a finely
divided solid suspended in an air stream with the properties
of liquid.
Fluoroscopy: Process of using an instrument to observe the
internal structure of an opaque object (as the living body)
by means of X rays.
Forced expiratory flow: The average rate of flow for a
specified portion of the forced expiratory volume, usually
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
between 2E-4 and 0.0012 mm3 (formerly called maximum
expiratory flow rate).
Forced expiratory volume: The volume of gas exhaled
over a given time interval during the performance of a
forced vital capacity.
Forced midexpiratory flow: The average rate of flow
during the middle half of the forced expiratory volume.
Forced vital capacity: The maximum volume of gas that
can be expelled as forcefully and rapidly as possible after
maximum inspiration.
Frequency- The number of cycles or pulses per second.
Functional residual capacity: The volume of gas
remaining in the lungs at the resisting expiratory level. The
resting end-expiratory level is used as the baseline because
it varies less than the end- inspiratory level.
Gallbladder: A small sac that stores bile.
Gamma system- Nerve fibers that reset the muscle spindle
to its adjusted length.
Ganglion: A mass of neuron cell bodies.
Gland: See endocrine gland and exocrine gland.
Glomerulus: The cluster of capillaries at the proximal end
of the nephron; the glomerulus is surrounded by the
Bowman’s capsule.
Gray matter: Nervous tissue in the brain and spinal cord
that contains the cell bodies, dendrite, and unmyelinated
axons.
Ground- A wire that makes an electrical connection with
the earth.
Heart block: A delay or interference of the conduction
mechanism whereby impulses do not go through all or a
major part of the myocardium.
Hemoglobin: The red iron- containing protein pigment in
the blood that transport oxygen and carbon dioxide and aids
in regulation of pH.
Heparin: An acid occurring in tissues, mostly in the liver.
It can be produced chemically and can make the blood
incoaguable if injected into the blood stream intravenously.
Hepatic: Pertaining to the liver.
Hertz- A unit of frequency equal to one cycle per second.
High-voltage current- Current in which the wave form has
an amplitude of greater than 150 volts with a relatively
short pulse duration of less than 100 sec.
Hormone: An organic chemical messenger that is
produced in one part of the body and transported to another
BB-54
part where it signals cells to alter some aspect of
metabolism.
Hydrocollator- A synthetic hot (1700 F) or cold (00 F) gel
used as an adjunctive modality to stimulate tissue
temperature rise or tissue temperature lowering.
Hydrocortisone- An antinflamatory steroid.
Hydrogymnastics- Exercises using the buoyant properties
of immersion in water.
Hydrostatic pressure- The pressure exerted by a liquid at
rest.
Hydrotherapy- Cryotherapy and thermotherapy techniques
that use water as the medium for heat transfer.
Hyperstimulation analgesia- See stimulus-produced
analgesia.
Hypertension: The elevated blood pressure develops when
the body’s blood vessels narrow, causing the heart to pump
harder than normal to push blood through the narrowed
openings.
Hyperventilation: Abnormally prolonged, rapid deep
breathing or over breathing.
Hypothalamus: Part of the brain that regulates the
pituitary gland, the autonomic system, emotional responses,
body temperature, water balance, and appetite; located
below the thalamus.
Impedance- Resistance of the tissue to the passage of
electrical current.
Indifferent or dispersive electrode- Large electrode used
to spread out electrical charge.
Induction electrodes- Electrical current is passed through
a coil that in turn gives off eddy currents of electromagnetic
energy. This energy is absorbed by the tissues and heating
occurs as a result of the resistance of the tissues.
Inferior vena cava: Main vein feeding back to the heart
from systemic circulation below the heart.
Infrared- The portion of the electromagnetic spectrum
associated with thermal changes; located adjacent to the red
portion of the visible light spectrum. That part of the
electromagnetic spectrum dealing with infrared
wavelengths.
Inspiratory capacity: The maximal volume of gas that can
be inspired from the resting expiratory level.
Inspiratory reserve volume: Maximal volume of gas that
can be inspired from the end-inspiratory position.
Iris: The pigmented portion of the eye.
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
Iuxtaglomerular apparatus: A structure in the kidney that
secretes rennin in response to a decrease in blood pressure.
Kidney: The paired organ important in excretion of
metabolic waste and in osmoregulation.
Korotkoff sounds: Sounds produced by sudden pulsation
of blood being forced through a partially occluded artery
and heard during auscultatory.
blood pressure determination.
Large intestine: The portion of the digestive tract
consisting of the cecum, colon, rectum and anus.
Larynx: The organ at the upper end of the trachea that
contains the vocal cords.
Lens: The oval, transparent structure located behind the iris
of the eye; bends incoming light rays and brings them to a
focus on the retina.
Liver: A large, complex organ that secretes bile, helps
maintain homeostasis by removing or adding nutrients to
the blood, and performs many other metabolic functions.
Low-voltage current- Current in which the waveform has
an amplitude of less than 150 volts.
Lumen: The cavity of a tubular organ or instrument.
Lung capacity: The amount of gas contained n the lung at
the end of maximal inspiration.
Lung: An internal respiratory organ that functions in gas
exchange; enables a person to breathe air.
Magnetic field- A technique of heating the tissues in
shortwave diathermy in which the patient is not part of the
electrical circuit.
Maximal voluntary ventilation: The volume of air that a
subject can breathes with maximal effort over a given time
interval.
Mechanical effects- Ultrasonic effects that involve
movement as a result of vibratory motion.
Membrane: A thin layer of tissue that covers a surface or
divides a space or organ.
Meninges: The three membranes that envelop the brain and
spinal cord: the dura madre, arachnoid, and pia madre.
Microshock- An electrical shock that is imperceptible
because of a leakage of current of less than 1 mamp.
Mitral valve: See atrioventricular valve.
Modulation- Refers to any alteration in the magnitude or
any variation in the duration of an electrical current.
BB-55
Myelin sheath: The white fatty material that forms a
sheath around the axons of certain nerve cells, which are
then called myelinated nerve fibers.
Nephron: The functional, microscopic unit of the kidney.
Nerve: A bundle of axons or dendrites wrapped in
connective tissue that conveys impulses between the central
nervous system and some other part of the body.
Nervous tissue: a type of tissue specialized for conducting
electrochemical impulses.
Neuron: A nerve cell; a conducting cell of the nervous
system that typically consists of a cell body, dendrites, and
an axon.
Neurotransmitter: A chemical messenger used by neurons
to transmit impulses across the synapse.
Norepinephrine- A neurotransmitter that may enhance
pain. When it is inhibited, analgesia is in creased. Increased
levels in the central nervous system decrease analgesia.
Norepinephrine: A neurotransmitter that is also a hormone
secreted by the adrenal medulla.
Occipital lobes: Posterior areas of the cerebrum; interpret
visual stimuli from the retina of the eye.
Ohm’s law- The current in an electrical circuit is directly
proportional to the voltage and inversely proportional to the
resistance.
Organ of Corti: The structure within the inner ear that
contains receptor cells that sense sound vibrations.
Organ system: Body system; an organized group of tissues
and organs that work together to perform a specialized set
of functions.
Osmotic pressure- The pressure for movement of a solvent
across a membrane that is permeable to that solvent.
Otoliths: Small calcium carbonate crystals in the saccule
and utricule of the inner ear; sense gravity and are
important in static equilibrium.
Ovary: One of the paired female gonads responsible for
producing eggs and sex hormones.
Ovulation: The release of a ovum from the ovary.
Ovum: female gamete.
Oxygen dissociation curve: A curve depicting the
percentage saturation of hemoglobin with oxygen, as a
function of certain variables such as oxygen concentration,
carbon dioxide concentration, or pH.
Oxyhemoglobin: Hemoglobin that has combined with
oxygen.
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
Pacemaker (of the heart): See sinoatrial node.
Pad electrodes- Capacitor type electrode used with
shortwave diathermy.
Pancreas: Large gland located in the abdominal cavity.
The pancreas produces pancreatic juice containing
digestive enzymes; also serves as an endocrine gland;
secreting the hormone insulin and glucagons.
Paraffin bath- A combined paraffin and mineral oil
immersion technique in which the paraffin sub stance is
heated to 126° F for conductive heat gains; commonly used
on the hands and feet for distal temperature gains in blood
flow and temperature.
Parathyroid gland: Small, pea- sized glands closely
adjacent to the thyroid gland; their secretion regulates
calcium and phosphate metabolism.
Parathyroid hormone: Hormone secreted by the
parathyroid glands; regulates calcium and phosphate
metabolism.
Pharynx: Part of the digestive tract. It is bounded
anteriorly by the mouth and nasal cavities and posteriorly
by the esophagus and larynx; the throat region.
Plethysmography: The recording of the changes in the
volume of a body part as modified by the circulation of the
blood in it.
Pulmonary circulation: The part of the circulation system
that delivers blood to and from the lungs for oxygenation.
Pulmonary minute volume (pulmonary ventilation):
Volume of air respired per minute= tidal volume*
breathes/min.
Pulsed ultrasound- Method of administering ultra-
Radiation- The process of emitting energy from some
source in the form of waves. A method of heat transfer
through which heat can either be gained or lost.
Radiograph- Record produced on a photographic plate,
film, or paper by the action of roentgen rays or radium;
specifically x-rays.
Repolarize- To return to a polarized state after a de
polarizing event.
Residual volume: Air left in the lungs after deep exhale
(about 0.0012m3).
Retina: The innermost of the three layers of the eyeball,
which is continuous with the optic nerve and contains the
light- sensitive rod and cone cells.
Rod: light sensitive cells of the retina that are particularly
sensitive to dim light and mediate white and black vision.
BB-56

Scrotum: The external sac of skin in males that contains
the testes and their accessory organs.
Secondary vasodilatation- Dilation following exposure to
cold to sustain viable tissues.
Semen: Fluid composed of sperm suspended in various
glandular secretions that is ejaculated from the penis during
orgasm.
Semilunar valves: Valves between the ventricles of the
heart and the arteries that carry blood away from the heart;
aortic and pulmonary valves.
Seminal vesicles: Glandular sacs that secrete a component
of seminal fluid.
Shawnn cell: Supporting cells found in nervous tissue
outside the central nervous system.
Sinoatrial node: Mass of specialized cardiac muscle in
which the impulse triggering the heartbeat originates; the
peacemaker of the heart.
Small intestine: Portion of the digestive tract that extends
from the stomach to the large intestine.
Sphygmomanometer: An instrument for measuring blood
pressure, especially arterial blood pressure.
Spinal cord: The dorsal, tubular nerve cord.
Spinal nerves: The nerves that emerge from the spinal
cord.
Spirometer: An instrument for measuring the air entering
and leaving the lungs.
Spleen: Abdominal organ located just below the diaphragm
that removes worn- out blood cells and bacteria from the
blood and plays a role in immunity.
Stomach: Muscular region of the digestive tract extending
from the esophagus to the small intestine.
Superior vena cava: Main vein feeding back to the heart
from systemic circulation above the heart.
Systole: The contraction, or period of contraction, of the
heart, especially that of the ventricles. It coincides with the
interval between the first and second heart sound, during
which blood is forced into the aorta and the pulmonary
trunk.
Systolic: Of or pertaining to systole.
Testis: The male gonad that produces sperm. The testes are
located in the scrotum.
July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez
Thalamus: The part of the brain that serves as a main relay
center, transmitting information between the spinal cord
and the cerebrum.
Thermal- Pertaining to heat.
Thermotherapy- The use of heat in the treatment of
pathology or disease.
Thyroid gland: An endocrine gland that lies anterior to the
trachea and releases hormones that regulate the rate of
metabolism.
Thyroid hormones: Hormones, including thyroxin,
secreted by the thyroid gland; stimulate rate of metabolism.
Tidal volume: Volume of gas inspired or expired during
each quiet respiration cycle.
Trachea: The main trunk of the system of tubes by which
air passes to and from the lungs.
Transducer- A device that changes energy from one type
to another.
Transmission- To pass through some medium.
Tricuspid valve: The valve connecting the right atrium to
the right ventricle.
Ultrasound- A portion of the acoustic spectrum located
above audible sound. Sound waves higher than the 16,000
to 20,000 Hz detectable by the human ear.
Ultrasound imaging: Technique in which high frequency
sound waves are used to provide an image (sonogram) of
an internal structure.
Ultraviolet- The portion of the electromagnetic spectrum
associated with chemical changes, located adjacent to the
violet portion of the visible light spectrum.
Ureter: One of the paired tubular structures that conducts
urine from the kidney to the bladder.
Urethra: The tube that conducts urine from the bladder to
the outside of the body.
Urinary bladder: An organ that receives urine from the
ureters and temporarily stores it.
Urinary system: Body system that consists of kidneys,
urinary bladder, and associated ducts.
Uterus: The hollow, muscular organ of the female
reproductive tract in which the fetus undergoes
development.
Vagina: The elastic, muscular tube, extending from the
cervix to its orifice that receives the penis during sexual
intercourse and serves as the birth canal.
BB-57
Vas deferens: One of the paired sperm ducts that connect
the epididymis of the testis to the ejaculatory duct.

Vasoconstrictions- Narrowing of the blood vessels.

Vasodilatation- Dilatation of the blood vessels.

Vasodilatation: Expansion of the diameter of blood

vessels.

Vein: A blood vessel that carries blood from the tissue

toward a chamber of the heart.

Ventricle: One of the chambers of the heart that receives

blood from an atrium.

Venule: A small vein; especially one of the minute veins

connecting the capillary bed with the larger systemic veins.

Vibration- A shaking massage technique; a fine tremulous

movement made by the hand or fingers placed firmly
against a body part and causing that part to vibrate. Often
used for a soothing effect; may be stimulating when more
energy is applied.

Viscoelastic properties- The property of a material to

show sensitivity to rate of loading.

Vital capacity: Volume of air that can be exhaled after the

deepest possible inhalation.

Volt- The electromotive force that must be applied to

produce a movement of electrons.

Voltage sensitive permeability- The quality of some cell

membranes that makes them permeable to different ions
based on the electric charge of the ions. Nerve and muscle
cell membranes allow negatively charged ions into the cell
while actively transporting some positively charged ions
outside the cell membrane.

Vulva: The external genital structure of the female.

Waveform- The shape of an electrical current as displayed

on an oscilloscope.

Wavelength- The distance from one point in a propagating

wave to the same point in the next wave.
Wavelength: The distance from one peak to the next;
energy from electromagnetic radiation is inversely
proportional to its wavelength.

White matter: Nervous tissue in the brain and spinal cord

that contains myelinated axons. Compare with gray matter.

β-endorphin- A neurohormone derived from β-lipo- tropin

and containing enkephalin. It is similar in structure and
properties to morphine. β-endor- phin has a half-life of 4
hours.

β-lipotropin- A pituitary hormone containing β-en-

dorphin and enkephalin and having opiate activity. [13]

July 10, 2004 Congress on Biofluid Dynamics of Human Body Systems at University of Puerto Rico Mayaguez BB-58