Clinical Decision Making

Haneul Lee, DSc, PT

Why electrical stimulation has been included in a plan of care? The initial evaluation should clearly delineate the goals of electrical

stimulation.

ES goals can easily be subdivided into the following major categories : pain relief, muscle strengthening/reeducation, edema control, facilitation of soft tissue healing, and transcutaneous delivery of therapeutic ions.

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Major Therapeutic Goals for the Use of Electrical Stimulation

Pain reliefMuscle

strengtheningEdema control

Soft tissue healing

Transcutaneous ion delivery

Steven B. Skinner, Christina McVey, Clinical making decision for physical therapy assistant, p.54

Monophasic (direct or galvanic current) A unidirectional flow of charged particles. A current flow in one direction for a finite period of time is a

phase It has either a positive or negative charge

Biphasic wave (alternating current) A bidirectional flow of charged particles This type of wave form is illustrated as one-half of the cycle

above the baseline and the second phase below the baseline. One complete cycle (two phases) equals a single pulse.

Polyphasic wave: biphasic current modified to produce three or more phases in a single pulse.

National Physical Therapy Examination, O’sullivan&Siegelman, TherapyEd, p.359

Continuous mode: uninterrupted flow of current.

Interrupted mode: intermittent cessation of current flow for > 1 second

Surge mode: a gradual increase and decrease in the current intensity over a finite period of time

Ramped mode: a time period with a gradual rise of the current intensity, which is maintained at a selected level for a given period of time, followed by a gradual or abrupt decline in intensity.

Pain modulation. Decrease muscle spasm Impaired ROM (increase in or maintenance of joint mobility) Muscle reeducation

(training muscles to respond appropriately to volitional effort) Disuse atrophy (muscle weakness) Soft-tissue repair (wound healing) Edema reduction Spasticity (ES to reduce hyper tonicity) Denervated muscle

Cardiac disease Impaired mentation In areas of impaired sensation, malignant tumors, skin

irritation or open wounds Applying iontophoresis in the area after the application of

another physical agent. In patients with hypotension or hypertension, excessive

adipose tissue or edema Bleeding disorders Menstruating uterus Pregnancy: during labor and delivery

Patients with demand-type pacemakers, unstable arrhythmias, suspected epilepsy or seizure disorder

Over or in the area of the carotid sinus, thrombosis or thrombophlebitis, eyes, thoracic region, phrenic nerve, urinary bladder stimulators and abdomen or low back during pregnancy

In the presence of active bleeding or infection Superficial metal implants Pharyngeal or laryngeal muscles

Although the same electrical stimulator may be used to treat a variety of conditions, the parameters for pain relief differ greatly from the parameters for edema control or muscle strengthening/reeducation.

Some electrical stimulators can only be used to achieve a single therapeutic goal -> TENS unit for pain relief

PTs must carefully survey the ES equipment at their disposal. High voltage or low voltage

Pulse duration (width) alteration

Ramp/surge settings

Associated with being sensitive to the patient’s safety and comfort.

Example 1

A relatively active patient with mild-to-moderate low back pain may benefit from immediate use of TENS for pain relief.A TENS effect may be administered via an ambulatory TENS unit,

part of the treatment session may be more active.

PTs must be able to assess the effectiveness of the various thermal modalities.

If a modality is used to manage pain, then pain assessments (VAS) should be performed immediately following its administration.

MMT, dynametrics, and functional tests can be used for effective monitor strength gains.

Circumferential and volumetric measurements can be used for effective monitoring of changes in edema.

Portable digitizers, digital cameras, and flexible rulers can be used to monitor size changes in open wounds.

Gate Control Theory

Electrode placement▪ PTs should not haphazardly pace electrodes.

▪ Placement should be based on clinical and academic knowledge and carefully documented.

Central Biasing Theory

Endogenous Opiate Theory

Electrode Placement

Over painful area

Over dermatome,

myotome, sclerotome

Over appropriate peripheral

nerveCrisscross

pattern

Over trigger points

Steven B. Skinner, Christina McVey, Clinical making decision for physical therapy assistant, p.57

PTs make clinical decisions concerning ramp time, pulse duration, and frequency.

Bipolar or monopolar technique is preferable.

Intensity

Duty cycle (on/off times)

Electrode placement

Ramp controls the rate of rise of the electrical stimulus. A slower ramp time may more closely mimic recruitment patterns and may enhance comfort.

Pulse width refers to the duration of the stimulus. Many low-volt stimulators allow for adjustment of pulse width. Longer pulse widths may enhance contraction without increasing intensity, thereby enhancing comfort.

Frequency refers to the number of electrical impulses generator per second. A smooth tetanic contraction is required for muscle strengthening. A series of stronger twitch-type contractions are appropriate for edema management. The lowest possible frequency to achieve desired results should be used.

A bipolar technique uses same-sized active and dispersive pads. It is primarily use for the stimulation of large muscle groups. A monopolar technique uses a small active electrode or probe and a distal large dispersive pad. It is used to stimulate smaller individual muscles.

Steven B. Skinner, Christina McVey, Clinical making decision for physical therapy assistant, p.58

PTs must follow the parameters and techniques as specifically detailed by the supervisor PT.

PTs must obtain the appropriate information prior to administering treatment.

PT’s clinical decisions must always be made in the best interest of the patient. Anytime the PT is uncomfortable making a clinical decision, the PT must seek guidance from a supervisor PT.

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Scenario

You are treating a patient with a diagnosis of bulging lumbar disc resulting in pain with flexion activities. The treatment plan calls for thermal modalities, electrical stimulation, passive lumbar extension exercise, and good body mechanic education. Your patient enters therapy today and says his pain is 6/10 on a pain scale. During the patient's treatment today, when would you give this patient electric stimulation?

Question?Thank

you

1. Clinical Decision Making for the physical therapist assistance, Steven B. Skinner, Jones and Bartlett Publishers

2. National Physical Therapy Examination, O’sullivan&Siegelman, TherapyEd3. PTEXAM the complete study guide, Scott M Giles, Scorebuilders