Everything highlighted in yellow → know it

Gonoimetry: Measure plantarflexion, stationary arm at fib head, moving arm at base of
5th met, axis at lateral malleolus!!!

Lecture 1 - PM&R
Modalities: physical agents; energy and materials applied to a patient to assist rehabilitation
● Thermal, mechanical or electromagnetic
● Not done because of not much evidence and with time limit and reimbursement not
worth it

Rehabilitation: everyone can provide this!

● Rehab is done by: Pt, OT, SLP, MD, DO, DMD, DPM, etc
● To restore a condition of good health, ability to work or the like
● A lot of people do rehab: you as a podiatric physician can bill for physical therapy
codes and do therapy with your patients
○ Use the same rehab CPT codes for billing but cannot claim to provide physical
therapy unless you have a physical therapy license
○ Cannot say that you are providing physical therapy unless you are licensed
physical therapist
○ If you offer therapy in your office as a DPM: you need to have a physical
therapy plan of care which is goal based
● Who does physical therapy? Only a licensed physical therapist
● Qualified professional means PT, OT, physician, PA, etc. who is licensed or
certified by the state to perform therapy services, and who also may appropriately
perform therapy services under Medicare policies

Physiatrist
● PM&R doctors - MD or Do, residency in physical med and rehab
● EMG nerve conduction study
● Non operative, independent
● Nerve muscle and bone experts
● Treat injuries or illness that affect how you move
● Decrease pain and enhance performance without surgery
● 4 years of med school, 1 year of internship, 3 year residency

Diagnosis
● Pathology = cellular level = physician (doctor makes the diagnosis)
● PT (nagi disablement model) - this is where the therapist intervene (4)
○ Impairment: organ or system level
■ Tight gastroc-soleus complex
 ■ Lack of dorsiflexion
■ Decrease strength
■ Pain
○ Functional limitation: restrictions to perform a physical task or activity in a
typically expected manner
■ Tight calf, leading to increase pronation in mid tarsal joint, cannot
run without pain now
○ Disability - how you are affected in your role in social context and
environment (person as a whole)
■ Professional football player can’t run
○ Handicap - impact society places on the individual’s disability, inability to
make adjustments
■ Disability that puts you in a wheelchair
● Updated: ICF: international classification of function and disability
○ Factors in: environmental and personal factors
■ Person can’t be in crutches and cane because they feel at risk in the area
they live in

5 elements of patient client management in PT

● Examination - required prior to any intervention
○ History, systems review and Tests & measures
● Evaluation - clinical judgment based on the data gathered during the exam
○ Considers level of impairment, functional limitation, and disability
○ If not potential for improvement (chronic arthritis), no goal → can’t keep them in therapy
● Diagnosis - label for the patient; not always needed
● Prognosis
○ Rehab potential - fair, poor, good, excellent
○ Predicted optimal level of improvement in function
○ Time frame to achieve
○ Plan of care
○ Goals
■ Short term goals - overcoming or improving impairments
● 4 weeks
● Weakness in plantar flexors, lack of dorsiflexion, achilles
tendonitis, pain in heel raises
○ Increase dorsiflexion to 5 degrees
○ Increase plantarflexion strength ½ to 1 muscle grade
○ Decrease pain from 8/10 to 5/10
■ Long term goals - function
● Discharge goals
● Return to jogging on treadmill
● Return to work as a construction worker
● Intervention - modalities
○ Last step
 ○ Different types of interventions, not only modalities

Elements of PT prescription/plan of care (prognosis) (5)

● Detailed written diagnosis - justify the need for a PT’s services
○ Pain alone is not sufficient
○ Join pain due to traumatic injury of the ankle is sufficient
● Document patient limitations and PT goals
○ You must document the patient’s objective and measurable functional limitations
as well as the expected value (goals) of the requested services
○ Patient is debilitated, limited, and deconditioned is not sufficient
○ Patient is unable to walk to the kitchen or bathroom without assistance.
Goal of therapy is to allow the patient to walk to the kitchen or bathroom
without assistance is sufficient
● Align patient goals with improvement or maintenance of the patient’s condition
○ Patient services must be directed towards a condition a patient has that is
expected to improve significantly within a reasonable and predictable
period of time
○ Or safe and effective maintenance program - at home
○ Realistic potential for rehab
● Relate PT services and results to your treatment plan
○ Written treatment plan
○ Quantify patient's condition and progress in terms of goals
● Spell out the PT procedures that you request when writing a PT script
○ Frequency and duration
○ Precautions and contraindications
■ Anything you don't want: critical to have on it

*Always have to get plan of care signed by the doctor*

*to discharge: don’t need to get doctor’s approval*
*medicare = most stringent guidelines and that what you want to follow*

Palliative care
● Not paid
● Relieving or soothing symptoms of a disease or disorder without effecting a cure
● Relieve or ease pain temporarily
○ Whirlpool to soften calluses prior to debridement

Restorative care
● Paid
● Expectation of significant improvement in a predictable period of time - skilled
care
○ Increase ROM of 1st MPJ from 40 degrees to 65 degrees dorsiflexion in 2
weeks post bunionectomy
Maintenance
● Not paid
● Care is designed to prevent deterioration of a particular condition with no
expected improvement
○ Home program - daily stretching to prevent contracture

Criteria for appropriate documentation

● Services must relate directly and specifically to an active written treatment
program established by a physician or the PT
○ Initial evaluation
○ Plan of care
● Services must be reasonable and necessary to the treatment of illness or injury
(measurable and objective)
○ Accepted medical treatment - is the documented service an accepted treatment
based on current literature regarding the particular condition? A single US tx. For
joint capsulitis or a bone spur is not
○ Requires skill and judgment of PT or DPM - service must be of a level of
complexity, or the patient’s condition complicated enough, that it would require
that a (PT/DPM) perform the services in order for it to be safe and effective
○ Functional and measurable gain - there must be the expectation that the
outcome will improve the patient’s condition in a reasonable, predictable time or
that a [PT’s] skill is required to establish a safe and effective maintenance
program
■ ROM of ankle has increased from 0 to 10 degrees in 2 weeks of
stretching
○ Amount, Frequency and duration

*key: measurable and objective terminology should be used*

*Reimbursement: clear documentation that connects the patient’s condition to the skilled
treatment necessary for reimbursement*

SOAP
● Subjective
○ Present diagnosis, PMH, complaints
○ Show need for skilled services
○ Patient goal
● Objective
○ ROM, tests, measurements
○ Should be enough to know what the patient has
○ Measured numbers - measure everything
○ Never use appears
○ Includes the treatment that you provided that day
● Assessment
 ○ Problem list
○ Goals - must modify goals as needed and must be very specific
○ Justify more PT or explain difficulties in meeting goals
● Plan
○ Frequency
○ Home care
○ Educate the patient
○ Equipment needed - walker, wheelchair
○ The exact treatment that you want
○ Discharge plans (discharge note)

Initial - everything
SOAP
Re-evaluation - every 4 weeks, compare and adjustments and make changed to plan of care
Discharge - HEP, equipment needed, D/C status, reason for D/C - you want to give exact
status when you discharge!

*once you no longer document functional improvement from a particular physical medicine
treatment, it become maintenance in character and is no longer reimbursable by third party
payers*

*everything in therapy = time based*

*all codes = time based; 15 min increments*
*document must be supported by the number of units billed and time spent in treatment*
*has to be at least 8 minutes into a unit before you can bill for it*

What to document?? A basic overview

● Gross posture - back, hips, knee, foot
○ Anteversion, retroversion, lordosis, varum, valgum, arch height
○ If something is less than a quarter inch, let it be!
● Palpation - skin temp, pain, tenderness, ligamentous gapping, joint play, sensation,
monofilament testing, edema (what type) and MEASURE IT
● Range of motion - ankle dorsiflexion with knee straight and bent, STJ motion (inversion
and eversion), knee range of motion and its effect on foot
○ Ankle: 0 = 90 degrees, towards head = dorsiflexion
○ Feet rest in plantarflexion and slightly inverted - equinovarus
● Manual muscle test - not test of strength, test of weakness (always check the
other side, but never at the same time)
○ Grades
■ 3, 4, 5 = commonly used
■ 3 or above = not reliable, really subjective
■ Below 3 = reliable because the criteria is much less subjective
■ If a patient can move against gravity, full ROM: ⅗
■ Moderate resistant: ⅘
 ■ Maximally resistant: 5/5
■ No palpable contraction (post op): 0
■ No movement at the joint but palpate and feel flicker of muscle -
trace contraction: 1
■ Siting and can’t dorsiflex, gravity eliminated (patient lie down on
their side), full range in gravity eliminated = 2
● >½ ROM in gravity eliminated but not full = 2-
● <½ ROM in gravity eliminated = 1+
● If you can give them a little bit of resistance in gravity
eliminated or less than ½ ROM against gravity = 2+
● Half ROM against gravity = 3-
○ Grades: 0, 1, 1+, 2-, 2, 2+, 3-, 3, 4, 5
● Break test
○ Very subjective
○ The amount of force necessary to overcome a patient’s effort when asked
to hold a specific position as compared to the opposite uninvolved side
● Functional test
○ Number of functional activities a person can perform as compared to the
opposite side or an established norm
○ Ask the patient to squat
○ Single leg heel raises - 20 consecutive heel raises
■ Need to consider age and sex of patient - older patients and females
do not score as well
■ Have them do the opposite side (normal side) and then compare to
the other side
● Myometric testing
○ Strain gauge or electronically tested force reading
○ More objective than MMT
● Isokinetic testing
○ Most objective muscle function test
○ Computer aided
● Balance
○ As you get older, balance gets worse
○ Proprioception
● Gait analysis - visual and instrumented

Lecture 2: Tissue Healing & Pain

● Tissue Healing: Rehabilitation protocols and progression are based on physiologic
responses of tissue to injury and the understanding of how various tissues heal
● Extracapsular ligaments have a higher propensity of healing
● Healing process
○ Inflammatory reaction
■ After injury the process of healing occurs immediately
 ■ Inflammation is a vascular (vasoconstriction) and cellular response
that serves to dispose of microorganisms, foreign material and dead
tissue
■ Redness (rubor), heat (calor), swelling (tumor), pain (dolor)
● 4 signs of acute inflammation, absent in chronic
inflammations
■ Without inflammation healing would not occur
■ Problem: inflammation becomes chronic
● Body never rids itself of the injuring agents and fails to get back to
homeostasis
■ Hemostatic response: blood coagulation and formation of platelet plug
and eventual clot hematoma
■ Vasoconstriction (margination occurs - walls of capillary become lined with
leukocytes -WBC) → hyperemia → stagnation
■ Secondarily: vasodilation - edema
■ Chemical mediators limit exudate and swelling after injury assisting
with cellular repair
● Histamine: vasodilation, increase cellular permeability,
removal of exudate through the cell wall
● Leukotaxine: margination (walls lined with WBC); prepare site
for tissue repair
● Necrosin: phagocytosis - remove toxin and debris out of the
area
○ Fibroblastic repair phase
■ Proliferative and regenerative activity lead to scar formation and
tissue repair
■ Begins within hours of injury - can last for up to several weeks
■ Capillary growth into the wound forms granulation tissue
■ Collagen forms but tissue is arranged in a random matrix - poor
tensile strength and not vascular therefore does not dissipate heat
■ Scar is fibrous tissue that you don't want to be thick over injured
site
■ Fibroblast cells migrate along fiber strands in areas of inflammation,
creating scar tissue
■ Fibroblast cells create an extracellular matrix: containing collagen
and elastin
■ As the collagen proliferates, wound repairs and becomes stronger
as the remodeling phase starts to begin
■ See signs and symptoms of inflammation disappearing
■ Rehab standpoint: begin some controlled activity
● Drawbacks if immobilize someone:
○ Muscles weakness and atrophy
○ Loss of motion, stiffness
○ Bone resorption - osteopenia
 ○ Cartilage: nourished via fluid movement, if joint
doesn’t move than fluid doesn’t move
○ Maturation - remodeling phase - can go on for months or years
■ Remodeling of the collagen fibers that make up scar tissue
● Collagen heals with tension on it
● Controlled, progressive stress/strain cause fibers to realign
parallel to tension lines
■ This is why we impart outside resistance tension, strain etc. to soft
tissue structure during the rehab process - allows for collagen to
reorganize in a controlled way
■ Wolff’s law - bone and soft tissue will respond to the physical demands
placed on them causing them to remodel and realign along tensile
force lines
● Plantar calcaneal heel spur - tensile forces
● Chronic achilles tendinopathy - only treat with modalities
(heat, ice, US)...you are not really helping the patient
○ Need to put controlled stress on it (tension on it) via
exercise to remodel the tissue

*therapist get sued: someone fell, burn, wrong exercise at wrong time and injured at
rehab*

Collagen
● Wound is the thickest around 14 days - but not very strong - fibroblastic phase
○ Dangerous deep because it its weakest and tendons have the risk of
rupturing: 12-22 week period of time
○ After this time period, you want to go to the right therapist because if you
don’t do anything, it will scar in
● As the wound matures, the crosslinks of collagen will become stronger and more
linear along parallel stress lines
● Overtime, decrease in thickness and increase in strength
● At about 1 month it has about 50% of its tensile strength
● 3-6 months increase vascularization
● 1 year mark: 82% of its original strength
● Enables tissue to resist mechanical forces (primarily tension)
● Type I: found in structures that resist tension - skin, tendon, muscle, annulus of a
disk
● Type II: found in structures exposed to compression - nucleus pulposus of a disk,
articular cartilage
● Primary structural component of ligaments, tendons, joint capsule and fascia,
also bone, cartilage and muscle
● Determines mechanical properties of all CT structures
○ Size and density of structure
○ Property of elastin and collagen in the structure
 ○ Ratio of collagen and elastin
○ Fiber arrangement

Factors that affect Repair

● Age - as we age, our tissue gets crapper
● Type of injury? Is it a recurrent injury? Ex: sprains - 1 ankle sprain = primary determining
factor of recurrent ankle sprains, limited dorsiflexion (pronator stress on foot)
● Edema
● Muscle spasm
● circulation/blood flow
● Diet and nutrition
● Meds (steroids/NSAIDS)

Rehab
● Ligament healing
○ Follows similar process of healing as other vascular tissues
○ Intra-articular vs outside the joint capsule - extracapsular ligaments heal better
than intracapsular ligaments because the synovial fluid prevents the fibrin
clot from forming and the tissue ends never get the chance to repair
○ During the vascular proliferation phase it is essential that the clot bridge the
gap of the frayed ends
○ Collagen synthesis will promote scar formation
○ Failure to produce enough scar and connect the damaged ends leads to
failure
○ MCL - extracapsular (heals well)
○ ACL - intracapsular (does not heal well)
○ Factors that affect ligament healing
■ Surgically repaired ligaments heal with decreased scar and are generally
stronger
■ With intra-articular tears the synovial fluid dilutes the hematoma and
prevents clot formation slowing healing
■ Exercised ligaments heal stronger than those immobilized → minimize
immobilization when possible and progressively (not aggressively) stress
the ligament
○ Lost joint stability due to ligamentous laxity must be compensated with
strengthening of muscle and tendon surrounding the joint
● Cartilage healing
○ Very limited healing capacity
○ Injuries to articular cartilage fail to form a clot
○ PT: must be conscious of joint reaction forces with exercise prescription,
avoid plyometric
○ Use orthotics for Hallux limited, Plantarflex the ray, more motion out of the
toe
● Skeletal muscle healing
 ○ Initially: hemorrhage and edema, followed by phagocytosis fibrosis and
scarring
○ Myoblastic cells form in the area which leads to regeneration of myofibrils
○ Active contraction of the muscle is critical to regain normal tensile strength
■ Can’t hypertrophy muscle
■ Can get the muscle stronger - neurologic response is improved
○ Strains commonly occur in large force producing muscles - medial head of
gastroc. (tennis leg)
● Tendon healing
○ Tendonitis (acute inflammation) vs. tendinosis (chronic condition)
■ Tendonitis: inflammation in tendon with true inflammatory signs
■ Tendinosis: none of the same acute inflammatory signs
○ Overuse tendinitis you must eliminate the aggravating condition…must have a
rest component
○ Sufficient healing requires dense union of tissue with extensibility and flexibility at
the attachment site
■ If fibrosis occurs, adhesions between tendon and surround tissue can
prevent smooth motion
■ Common after achilles injury/immobilization

Instrument Assisted Soft Tissue Mobilization (IASTM) - promote fibroblastic proliferation

in direction of stress
● Gua Sha - scrape skin
● Theory
○ Color and rate of fading are diagnostic and prognostic
○ May cause bruising and petechiae (not the goal)
■ Theory: increased amount and duration of erythema = indicative of
severity of problem
■ Hypothesis: petechiae is result of release of hardened scar tissue for
healthy soft tissue
○ Quicker petechiae/erythema seem to have more myofascial pain, poorer
tissue quality
○ Response tends to decrease over time
○ No more than 2 minutes!
● Theories of how it works
○ Expands and exploits principles of transverse friction massage
● Microtrauma to tissue creates inflammation - facilitates healing tendinopathies -
chronic patient, not acute
○ Chronic muscle pulls
○ Scar tissue
○ Inflammation: reguide tissue for healing
● Facilitation of CT healing - quickstart the inflammatory process
● Promotes fibroblastic proliferation (ultimate goal of Tx)
● Benefits
 ○ Neuromodulation of tone and pain - if patient has muscle spasms, you can
decrease tone
○ Microtrauma (PRP, prolotherapy: saline)
○ CT healing - activates alignment of fibroblasts and myofibroblasts in direction of
stress
○ Release of adhesions/fascial restrictions
○ Increase circulation - somewhat superficially

Pain
● Unpleasant sensory and emotional experience associated with actual or potential
tissue damage
● Reaction to the perception of noxious stimuli
● Is and experience based on both physical and psychological processes
● Will be the primary reason the majority of patients come to see you

Types of pain
● Acute
● Persistent -
● Chronic - start after acute injury or be from a chronic illness or have no known cause,
pain lasting longer than 6 months
● Referred - pain in an area that is distal to where the source is
○ L4/L5 radiculopathy - can present with a purely sensory component → hits L5
nerve root → lateral leg!
■ Radiculopathy = any pathology that causes nerve root pinching in
the spinal column
● disc herniation, affects the bigger number, if its bone related
(osteocytes), affects the smaller number
● Ask the right questions!
○ Open ended: describe your pain
○ Close ended: is it a burning sensation?
○ What causes your pain? What makes it worse? Better? Does it cause you to lose
sleep?
■ Nocturnal pain can be a sign of cancer! Need to rule it out, once it is…you need
to help the patient to sleep, if they don’t get a good night of sleep → agitated and
irritable

Pain Assessment
● Numeric pain scales: Pain 0-10 → give the patient the chance to not have any pain!
● VAS - visual analog scale
○ 10cm line
○ Patient asked to mark line on a scale corresponding to their level of pain
○ Take measure from no pain to point marked
○ Can be done daily, on re-eval etc.
 ● Pain questionnaire - McGill pain questionnaire; 78 words and grouped into 20
subgroups, and divided into 4 sections, higher the number, worse the pain level
● Pain charts - have to be careful with this, the patient gets extra creative!!!

Sensitive Structures
● Periosteum and joint capsule - highly innervated
○ Dislocated shoulder
● Subchondral bone, tendon, ligament
● Muscle and cortical bone - less discomfort
○ Acute gastroc strain

*What spinal tract is responsible for pain and temperature sense? Lateral spinothalamic
tract*

Afferent = sensory, toward brain

Efferent = motor, brain to periphery

Afferent neurons - gate control

● AB: large diameter sensory neurons
● AS (ADelta): small diameter sensory neurons; pain info
● C: small diameter sensory neurons; pain info

Gate Control Theory

● If SG is inhibited, pain signal goes to brain
○ AS(Adelta) and C fiber = stimulated when you have pain
● If SG is facilitated, pain signal is blocked
○ AB fiber = apply TENS

Thermal Agents and PAIN

● Heat
○ Counter-irritant - gate theory
○ Increase blood flow → removes metabolites
○ Reflex inhibition of muscle → decreases spasm
● Cold - USED ACUTELY
○ Counter irritant (gate theory)
○ Decrease NCV’s → affecting small diameter afferent fibers
○ Vasoconstriction
Lecture 3: Superficial Heat Modalities
Sources of Heat
● Chemical - exothermic reactions
● Electrical currents - electric heaters
● Mechanical work - friction

Heating depth
● Superficial heaters: < / = 1cm in depth, if a tissue is deeper than that, it will not get
heat
○ Example: reduce muscle spasm
● Deep heaters: up to 5cm
○ Example: ultrasound - muscle tissue in the thigh

How hot will it get?

● Dependent on:
○ Source
○ Intensity
○ Length of application
● And:
○ Volume of tissue exposed
Contraindication to applying heat:
● Don’t want to heat up an implant
● Tissue is already damaged - fibrotic tissue (scar) because the blood flow is not good
○ Blood flow coming in dissipates the heat and prevents the blood
○ If you have poor blood flow, risk at burn

Applying heat:
● Conduction: transfer of energy from one hot body to a colder or cooler body, some type
of molecular collision, two bodies touch
○ Moist heat packs and paraffin wax
● Convection: movement of mass across a body to transfer heat
○ Whirlpool and fluidotherapy
● Radiation: object (does not get warm) between source of heat and thing you are heating
○ Infrared lamp
● Conversion: converting another source of energy into heat
○ Ultrasound and shortwave diathermy

Physiologic Responses
● Metabolic
○ Increased temp = increased metabolic rate
○ More nutrients available for tissue healing because of increased oxygen uptake
■ Increase in blood flow, oxygen comes in and healing occurs - therapeutic
benefit of heating
○ Law of Van’t Hoff - for every rise in 10 degrees C, the rate of oxidation is
increased 2 and half times
■ The hotter the body gets, the more chemical reactions
○ As temperatures rise above 115 - 120 degrees F human tissue will burn as
body cannot keep up with the protein denaturation from the high heat
● Vascular
○ Superficial heaters cause vasodilation - skin turns red because capillaries
start to dilate and increase blood flow
■ Axon reflex
■ Chemical mediator release - histamine, PG release
■ Local spinal cord reflex
○ Skeletal muscle blood flow primarily controlled metabolically
■ Because deep than 1cm in most spots
■ Moist heat along with exercise had better heating effect than heat or
exercise alone
○ Vascular response
■ Normal response
● Quick vasoconstriction
● Then start to vasodilate and
● then plateau
 ■ PVD patient, scar tissue
● Vasoconstriction
● Then vasodilate
● Never plateau
● Blood flow is poor, and no heat dissipation → higher risk of burn

*tissue temperature must be elevated to between 104-113 for therapeutic effect

(increased metabolism and increased vasodilation)*

● Neuromuscular Response
○ Pain relief and analgesia
○ Decreased muscle spasm
■ Elevates pain threshold
■ Alters sensory nerve conduction velocities
■ Changes muscle spindle firing rates
● Decreased firing of type II afferents - responds to changing in
length
● Increase firing of type Ib fibers from GTO - responds to
changes in tension
○ Deep structure: reflexive - decreased gamma efferent activity
○ Decreased strength
○ Decreased endurance
● CT effects
○ Heat and stretch increases the viscoelastic properties of CT (increase
length of CT)
○ Factors involved
■ Temperature elevation
■ Stretch intensity, duration and speed
○ Permanent elongation?
■ Stretch and immobilize
■ Constant load (low load), enough to overcome tissue resistance
■ Constant rate of stretch
○ TERT: total end range time
■ The longer you hold the joint at end range of motion the better
deformation of tissue you will get

Superficial Heaters
● Heat tissue up to 1cm deep
● 6-8 minutes to maximal heat
● May have reflexive benefit on deeper structures
○ Reduced muscle spasm in deep erector spinae muscles through reflex
mechanism
● Modality selection is multifactorial
Contraindications
● Active bleeding
● Hemophilia
● Active Fever
● Acute injury (48-72 hours)
● Patients with poor tolerance to heat (MS patients)

Precautions
● Sensory changes
● Poor circulation (PVD)
● Malignancies (never heat tissue that has known malignancy) / history of radiation
● Established edema - pros and cons
● Poor skin turgor (elderly)

*#1 cause of lawsuits among PT’s = burns*

Examples of superficial heaters (5)

● Moist heat packs - conduction
○ Can’t bill for it
○ Hydrocollator with temp. At about 175 degrees
○ Pack in cover and apply towels on top - 6 to 10 layers
○ 12-20 minutes
○ Examples
■ Lower back pain
■ Gastroc (pre-stretch)
■ Plantar aspect of foot
■ Anterior compartment (pre-stretch)
■ Calf before stretch
○ Advantage
■ Easy to apply, does not require constant attendance, cheap
○ Disadvantage
■ Does not contour well around the ankle and foot, pt. Can’t exercise
with it on
○ *always inspect skin*
○ Use as an adjunct to treatment. Desired outcomes will not occur with
modalities alone!!!
● Paraffin wax - conduction
○ Hot wax set to a temp of 118-130 F
○ Dip and wrap, dip and immersed
○ 12-15 minutes
○ Example
■ Toes and hands - stiffness, bunion, jam your finger
■ Distal extremities
○ Advantages:
 ■ Even heat distribution, ideal for irregular surface anatomy, can
retain heat by wrapping body part, leaves skin warm and pliable
○ Disadvantages:
■ Can be messy, pt. Must wash body part pre-treatment
○ Contraindications
■ Open wounds, dermatitis, fresh skin grafts, acute scars
● Whirlpool - convection
○ Buoyancy: upward force equal to the weight of the displaced liquid
○ Pressure: water exerts perpendicular pressure against surface of the body -
dependent on density of fluid and depth of the submerged body part
○ Cohesion: water molecules attract each other creating increased viscosity and
increased resistance to motion
○ Water bath in which water is agitated by an electric turbine
○ Convection
○ Massaging effect
○ Add things to reduce or prevent infection: betadine
○ Can be warm or cold
○ Benefits: exercise during, hydrostatic pressure can increase lymphatic
circulation
○ Triple arthrodesis - surgery, open wounds and burns, subacute and
chronic pathology due to traumatic and inflammatory conditions, PVD,
sprains/strains, contracture, acute ankle sprain
○ Contraindications: infections can spread, acute inflammation, cardiac and or
respiratory instability, HTN, malignancies, active bleeding, grafts and flaps,
destroys new growing tissue
○ 98-110 degrees (hot), 55-65 for cold, 15-20 minutes, someone needs to be
there all times
● Fluidotherapy - convection
○ Dry heat transfer through convection method
○ Cellulose particles (cellex) suspended by forced air
○ Temp 102-118
○ Control amount of particle agitation
■ Helpful to desensitize
■ Not for someone who is hypersensitivity
○ Edema - hands
○ Advantages
■ Uniform heating, easy temp control, easy agitation control, allows pt to
exercise, pressure may help with edema, use with wound but must
cover them
○ Disadvantages
■ Expensive and messy
● Infrared lamp - radiation
○ Heat lamp, never used anymore
○ Inverse square law: I = 1/d2
 ■ Increase distance will decrease intensity
■ Small distance change = large intensity change
○ Cosine law: greatest intensity is at a right angle
■ Perpendicular to the body for max heat transfer

Examples
● Stiff 1st MTP joint - paraffin
● Gastroc strain - moist heat pack
● s/p triple arthrodesis - whirlpool

Lecture 4: Deep Heaters: (2)

● Ultrasound - conversion
○ Use high frequency sound waves >20,000 Hz to deliver heat by conversion
○ Reverse piezoelectric effect is applied as voltage deforms crystal, and results
in vibration, which allows the transducer to convert alternating current/ electric
energy into sound energy
■ The crystal is inside the sound head of the US unit
■ AC current causes the crystal to expand and contract which causes
the soundhead to vibrate
■ Transducer converts electrical energy into sound energy
○ Medical US is a .8-3 mHz penetrating 3-5cm
○ 1 MHz → depth of penetration of up to 5cm (if not given a choice)
○ 3 MHz → depth of penetration of up to 2-3cm - we use this one in podiatry!
○ Can either swap out sound heads or control the frequency directly on the
display of the unit
■ If doing a wrist, don’t want a gigantic sound head
■ Ankle (irregular surface area), small because if sound head not
constantly touching skin, create a hotspot and burn the patient
○ Duty cycle
■ Time on/ time on + time off
■ Continuous or pulsed (100, 50, 20%)
● Continuous: constantly on → trying to generate a thermal effect -
100%
● Pulse: reducing the heating effect
○ 50% on and 50% off: not much of a thermal effect
■ If you decrease duty cycle, you decrease the heating effect
○ Thermal effects
■ Increased tissue extensibility
■ Reduction of muscle spasm - heating the tissue directly
■ Decreased pain
■ Increased blood flow
○ Non thermal effects
 ■ Massaging effect with application
■ Separation of collagen fibers with resultant increases in the extensibility
of CT - decrease scar formation
■ Increased membrane permeability, allowing for increased ionic
exchange and protein synthesis (acoustic streaming)
○ Effects
■ Absorption of US energy is dependent on
● Protein content - more the US energy is absorbed
○ Bone, nerve, muscle, fat (most to least)
● Homogeneity of tissue - more homogenous, the less US
energy absorbed
○ Fat, metal and synthetic implants = very homogenous
○ But structures around them will heat up because they
absorb that energy - need to be careful
■ Acoustic impedance: greatest heating occurs in areas of greatest
differences in tissue density
● Bone-muscle interference
● Soft tissue near bone will receive a significantly higher dose
of US energy than the soft tissue at the surface…heating from
inside out
● Patient should not feel heat early on
○ If they do
■ Crystal is broke and will give them a burn
■ US has a head warmer on it - to keep the gel
warm
○ Need to do it for 8 minutes in order to bill! (15min, so need to be more than
half way through it to bill for it)
○ Intensity
■ ERA (effective radiating area, size of crystal) = total watts / W/Cm2
■ Rule of thumb: 1.5 w/cm2 or 9 total watts (should not exceed)
■ Just because it looks big, does not mean the crystal inside is big
● If both US machines are both set to 1.5w/cm2, the one with
bigger wattage contains a bigger crystal (6 W vs 2.6 W)
■ Longer treatment times with higher intensity are required to heat deep
muscle tissue
■ If your doing this and the patient pulls away and feel a shock → induced
periosteal pain
○ Need to constantly keep the sound head moving when using US to produce a
thermal effect
○ Indications
■ Tendonitis - can cause an increase in pain because right by bone, there is
inflammation and if you add heat to it…gets worse
■ Muscle spasm/trigger points
■ Bursitis - same thing as tendonitis though
 ■ Scar tissue/joint contracture
■ Calcium deposits
■ Wound healing - 3MHz pulsed in water or with gel around wound edge
■ Edema - 1 or 3MHz pulsed
■ Bone healing - low intensity pulsed
■ Identifying fracture - 1MHz continuous (should not get pain, but if there is
pain..yes!)
○ US 100% continuous
■ Thermal heating effect! - therapeutic
■ Intensity 1-1.5 intensity
■ Frequency: 1 or 3 depending if deep or superficial
■ Medium - gel
■ Keep sound head moving on area to avoid energy concentration and
patient discomfort - patient can develop periosteal pain if you leave
US in same location for too long
■ Dosage governed by power and time
■ Time is about 5-10 min (8 minutes)
○ US under water
■ Instead of gel, water as medium
■ Irregular surfaces - ankles and wrists
■ Plastic basin (don't want to heat up the water)
■ Move the sound head around but increase the intensity about .5cm
to 3cm because not right on the skin
■ Do not do it in aerated water (bubbles are poor conductors/impede
soundwave transfer)
○ Phonophoresis
■ Pulsed US to drive medication through the skin - usually an anti-
inflammatory compound (hydrocortisone)
■ Used for plantar fasciitis and achilles tendonitis
■ But does not work
■ Iontophoresis - uses electric current (direct current) to push it
through the skin
● Can work (some benefit)
○ Contraindications
■ All general heat contraindications
■ Never over testes, eyes, spinal cord (do not want to heat up CSF)
■ Never over uterus (low back) of possibly pregnant patient
■ Never over growth plate of young children
● Shortwave diathermy - conversion
○ Deep heater and it exists
○ 2 methods of application
■ Condenser field method: patient becomes part of circuit of electrical
flow
 ■ Induction method: patient not part of circuit but you induce current into
patient
○ Magnetic field → current in patient → creates heat
○ Very good at heating tissue with high water content
● Microwave diathermy

Lecture 5: cryotherapy
Application methods
● Cold packs
● Ice massage - done in the clinic
● Ice towels
● Cold baths/whirlpools
● Vapocoolant sprays - prior to injection
● Cold compression units

Hemodynamic effects
● Reflex vasoconstriction
● Increase blood viscosity - makes blood thicker
● Decrease vasodilator metabolites
● Direct action of cold on smooth muscle results in contraction (BV)

Physiologic Responses to cold

● Decreased skin temp (<1 min)
● Decreased subcutaneous temp
● Decreased muscle temp - dependent on how deep the muscle is
○ Less than 30 minutes to decrease muscle temp 4.3cm deep 3.5 degrees
centigrade
○ It takes 30 minutes to effect a 6.3 degrees F temp reduction in a muscle 1.6”
deep using ice packs
● Decreased intra-articular temp
● The deeper the tissue the longer the application required

The Hunting Response

● Tissue demands O2 so vasodilation occurs, then constriction, then dilation,
continues to cycle
● Always in relatively constricted state
● Directly related to core body temperature
○ Only works in a warm core body temperature relative to the surrounding
(putting hand in bucket of ice)
○ If in Antarctica and core body T is low, then there is no Hunting response
● Only be useful to prevent damage in tissues, if the person can maintain warm
core body temperature during exposure to survive cold
Effects on peripheral nerves
● Decrease nerve conduction velocities (NCV) - could be good or bad
● Can decrease or block sympathetic activity
● Be Careful of neuropraxia

Effect on muscle spasticity

● Can reduce spasticity
○ Decrease discharge of type Ia and II afferents (muscle spindle)
■ Decrease neural input in the spindle which responds to changes in
length

Effect on muscle strength

● Controversial
● Decrease strength because decrease muscle conduction velocity

RICE
● Rest
● Ice
● Compression
● Elevation

*Acutely: never heat, always ice!!!* go into RICE

Application methods and response

● Brief application
○ Peripheral vasoconstriction
○ Increased HR, RR and metabolic rate
○ Shivering
● Prolonged application
○ Peripheral vasodilation
○ Redness of skin
○ Decreased HR and RR
○ Decreased NCV
○ Decreased body temp
○ Slowed body functions
○ Decreased tactile sense (harder to do 2 point discrimination)

Cold packs - used a lot in clinic

● Silica gel encased in vinyl
● Stored at -5 degrees for at least 2 hours
● Stay cold for about 15-20 minutes (good 10 min, 15 at most)
● Can apply moist towel between pack and skin
● Alternatives: bag of ice, frozen peas, etc.
Ice Massage
● Used over small areas
○ Trigger points, bursae
● 4 sensations
○ Intense cold
○ Burning
○ Aching
○ Analgesia
● Massage effect may enhance benefit with collagen repair
● Great for achilles, insertional achilles tendinopathy
● 5 minutes continuous over the pain area

Vapocoolant Sprays/ spray and stretch

● Know it exists!

Cold Compression units - game ready

● Great for ankles and knees
● Common post-op
● Bill for vasopneumatic device
○ No one pays for hot and cold packs
● Greater tissue temperature decreases are achieved with medium and high
pressure settings when using the game ready

Precautions
● Cold urticaria - hypersensitivity, wheals, erythema
● Cryogobinemia - abnormal blood protein - gel at low temps.
● Cold intolerance
● Raynaud's - fingers get white
● PVD
● HTN - may aggravated because of vasoconstriction (cold baths)
● Be Careful with diabetics - poor temperature regulation because of microvascular
damage, no correlation to severity of disease and length of recovery time

Intermittent Pneumatic Compression (IPC) and edema control techniques

● Apply (air, manual, etc) pressure to the outside of an extremity which in turn increases
the pressure of fluids in the interstitial space and theoretically, leads to return of the
fluids to venous and lymphatic system
● Lymphedema: swelling of the subcutaneous tissue deep to obstruction, destruction or
hypoplasia of lymph vessels and accumulation of lymph fluid
○ Primary: present from birth or develops during puberty (due to hypoplasia of BV)
○ Secondary: from infection, radiation, surgery, lymph obstruction
● Problems: contracture/ decreased ROM, pain, wounds, circulation problems, impaired
function
● IPC devices
 ○ Basically an air compressor attached to an inflatable sleeve
○ Adjustable: pressure (mm/hg), on time, off time
○ Seleves:
■ Unicompartmental: 1 compartment and the entire thing fills with air
● Drawback: can’t focus on a specific area and because its your leg,
not segmental, will not push from distal to proximal
■ Non-gradient segmental: sleeve = different compartment and each
compartment has same amount of pressure in it, turns on from distal
to proximal (segmental)
■ Gradient segmental: compartment and set specific amount of
pressure in each compartment - most of my pressure distal, less
pressure on wounds
○ Guidelines
■ UE pressures usually not to exceed 40-60 mmHg
■ LE pressure usually not to exceed 50-70 mmHg
■ Usually never exceed diastolic BP
■ On:off ratio = 3:1 for edema
■ TX time - 2-3 hours, get them a home unit
■ Adjunctive to using other things
○ Contraindications
■ CHF - can’t force fluid back into the system when they have congestive
heart failure!!!
■ DVT
■ Acute or nonunion fracture
■ Acute edema
■ Cellulitis
■ Dermatologic infection
■ Not prescribed for bilateral symptoms because they can have
something from systemic going on with them

Pressure Garments
● Jobst stockings
● Maintain reduction of edema, assist with venous return and can decrease with
scar formation (compression gives collagen a little bit of tension)
● OTC, RX, custom fit
○ Under 20mmHg = OTC
○ Excess 20 mmHg = RX

Edema Control
● Manual lymphatic drainage → gold standard
○ Who does it? Therapist!
○ Common in UE in women with breast cancer and have had lymph nodes
removed
● Ace wraps
 ● Coban (apply directly on the skin - helps reduce swelling but if the patient leaves it on for
long periods of time, skin will break down)

Lecture 6: Electrical Stimulation

● Not all E-stim is the same, depending on the waveform used, has a different
impact on the patient
○ Iontophoresis - direct current and can burn someone
○ TENS - pulse, can’t burn someone

Clinical indications
● Pain (IFC and TENS)
● Alternating (RussianStim) or pulsed currents (NMES)
○ Muscle strengthening
○ Muscle spasm
○ Spasticity
○ ROM return
● Orthotic substitution (FES) - quad contraction
● Iontophoresis (DC)
● Wound healing (Hi-volt, DC)
● Edema control (microcurrent, galvanic)

Equipment
● Clinic units (plug in models)
● Battery powered units
○ Electrodes
○ Lead wires

Types of current
● Direct current - constant, one side is continuous, high chance of burns, constant
polarity
● Alternating current - no off time ever, not even on both sides, + and -
● Pulse current - brief off time between pulse, one or both sides

Waveform characteristics
● Phases - change in shape of wave
● Symmetry - symmetric vs. asymmetric
● Change balance

Time dependent characteristics

● Pulse duration: time it takes for wave to leave isoelectric line and finish its pulse
○ Measured in msec or usec
● Rise time: time pulse takes to reach peak amplitude
● Decay time: time to get from peak amplitude back to iso-electric line
 ● Interpulse interval - time between 2 successive pulses
● Frequency = rate
○ Pulsed current = pps
○ Alternative current = cycles/sec (Hz)
Current modulations
● Amplitude modulations
● Pulse duration modulations
● Frequency modulation
● Trains or bursts - russian stim
● On time/off time
● Duty cycle: current is on then it is off

E-stim
● The frequency (rate), amplitude and pulse duration are usually adjustable (pulse
duration may be pre-set) and allow us to manipulate the stimulation to produce one
of 3 response
○ Sensory stimulation - feel it
○ Muscle twitch - motor contraction
○ Tetanizing muscle contraction - full contraction

Electrode basics
● Placement
○ Monopolar: single electrode placed over the target area and other electrode
(dispersive/ground) placed far away to complete circuit
■ Iontophoresis - direct current
○ Bipolar: 2 or more electrodes are placed to effect the target area
■ Russian stim, TENS, interferential, portable units

Electrode size
● Small electrode
○ More current density
○ Less current spread
○ Better selectivity
○ More painful contraction (if producing motor response because need to stimulate
it more to get a motor response)
○ Not favorable if trying to get quad to contract because a big surface area
● Large electrode
○ Less current density
○ Greater current spread
○ Less selectivity
○ Stronger contraction without pain

Electrode materials
● Metal and sponge
 ● Carbon impregnated silicone rubber
● Pre-gelled self-adhering disposable

Factors affecting transmission - do not conduct good electricity

● Skin impedance: dirt, lotion, sweat
● Dispersion from gel smearing
● Incomplete gel coverage
● old/dirty electrodes
● Subcutaneous fat
● Edema

So what are we stimulating to get a contraction?

● Intact PNS? - what we see more
○ Peripheral nerves - neurolemma of the axon
● Denervation? Foot drop, bell's palsy
○ Sarcolemma of the muscle so you can get a contraction but you are not
stimulating the nerve!!!
○ Takes a long time - 10 ms or longer

Producing AP in nerves, when the stim is applied, the Resting membrane potential is -65mV and is
altered as sodium ions rush in → depolarization* All or nothing phenomenon

Contraction Comparison
● Physiologic contraction
○ Nerve excitation: stimulus must be of adequate intensity and duration to reach
threshold
○ Motor unit recruitment: asynchronous firing pattern
○ Anatomic: stimulation from within and throughout the muscle
○ Recruitment activity: CNS stimulates small diameter fibers then large
diameter
○ Metabolic residue: build up of byproducts - lactic acid
○ ACH: stimulation of nerve fiber causes release of ACH. The supply of ACH
always exceeds the demand
● Electrically stimulated contraction
○ Nerve excitation: stimulus must be of adequate intensity and duration to reach
threshold
○ Motor unit recruitment: synchronous firing pattern - all fire at once
○ Anatomic: stim is transcutaneous with increased intensity superficially
○ Recruitment activity: large diameter fibers stimulated first
○ Metabolic residue: build up of byproducts
○ ACH: stimulation of nerve fiber causes release of ACH. high frequency stim
may cause depletion of ACH faster than it is produced - potential to fatigue
someone out faster
Clinical Application - muscle strengthening
● NMES - neuromuscular electrical stimulation
○ Utilization of electrical current to improve motor control, increase strength,
encourage muscle retraining, or reduce muscular spasm
○ Can also be functional electrical stimulation: walkaide for foot drop
○ Typical current used
■ Pulsed Bi-phasic
■ Russian stim - burst AC - usually used for strengthening, post-op
● 2500 Hz carrier frequency packaged into 10 ms increments
● Usually 1:5 ratio
○ Strengthening occurs through the overload principle
■ With stim the force is increased by increasing the current intensity
■ Limited by patient tolerance and fatigue
○ In healthy humans combo of e-stim and exercise showed no greater gain than
either intervention alone
■ Don’t buy the product!
○ To produce strength gains in healthy humans intensity must be at least
50% MVIC (maximum voluntary isometric contraction)
○ To produce strength gains in injured patients studies show intensities as
low as 10% MVIC can be helpful
○ Adding E-stim along with exercise enhances strength return in weak
patients

Clinical pearls
● Explain and scare
● Jump start in patients with neurogenic inhibition
● Asymmetric current for small muscle groups and symmetric for large groups
● Foot and ankle
○ Foot drop / anterior tib weakness
○ Gastroc strengthening
○ Peroneal spasm - fatigue failure
○ Selective muscle reeducation

Not getting the desired response?

● Check electrode placement (increase electrode size)
● Increase current frequency
● Increase ramp (for comfort)
● Last choice - increase amplitude

Clinical applications - pain relief

● E-stim for pain relief → gate theory
○ Trick my brain into feeling sensation of stim, instead of the discomfort
Pain relief: TENS or IFC = gate theory
● Transcutaneous electrical nerve stimulation
● Pulsed biphasic waveform
● Traditional TENS
○ Short pulse duration (50-80)
○ Sensory stimulation
○ Pulse frequency b/t 100-150 pps
TENS
● 1 or 2 channel set up
● Wear time
● adaptation/ accomodation
● Noxious stim
● Trigger point stim

IFC - interferential current

● Same mechanism of action - gate theory
● Involves crossing the pathways of two un-modulated sine waves of different
frequencies
● Requires 2 channels - 4 electrodes

E-stim for pain control parameters

● Usually start with sensory stimulation for pain modulation
● Can augment treatment with moist heat or ice
● traditional/ conventional TENS - short pulse duration (width) and high pulse
frequency
● Patients will accommodate to the current over time and will need modifications to
the parameters you set
● Once edema is established, estim won't be able to help but may be used
preventatively