What is Physical agents

There are three type of treatment, 1,Medical, 2,Surgical, 3,Physical Medical & Surgical are known but the Physical needs to be highlighted. All natural agents were the Remedies used by the Therapist before modern technologies Like, Sun, Heat, Light, Water, electricity & Therapeutic Movements of the body

What is Physical Medicine

Now the natural agents have changed to
modern technology/science in the form of ENERGY. Like. Heat ENERGY ; infrared & ultraviolet radiation Sound ENERGY ; ultrasonic therapy Electro magnetic ENERGY; SWD,MWD

Electrical ENERGY; TENS, Interferential current,

electrical stimulation, dia dynamic current etc. Mechanical ENERGY; different types of therapeutic exercises, manipulation and mobilization

COMPONENTS OF ELECTRICAL CURRENTS

ELECTRICAL CURRENTS The flow of
electron in a conductor is known as electric current ,it always go from the higher potential to lower potential. The unit of measurement at which the electrical current flows is called the ampere (A) Amperes indicate the rate of electron flow. whereas coulombs indicate the number of electrons

COMPONENTS OF ELECTRICAL CURRENTS

In the case of therapeutic modalities,
current flow is generally described in milliamperes (1/1000 of an ampere, denoted as mA) OR microamperes (1/1,000,000 of an ampere, denoted as A

COMPONENTS OF ELECTRICAL CURRENTS

Electrons can move in a current only and
materials that permit this free movement of electrons are called conductors. Like metals (copper, gold, silver, aluminum) are good conductors of electricity Materials that resist current flow are called insulators. Insulators contain relatively fewer free electrons and thus offer greater resistance to electron flow like Air, wood, plastic ,rubber and glass are all considered insulators.

Types of Electrical Current

Electrotherapeutic devices generate three
different types of current that, when introduced into body tissue, are capable of producing specific physiologic changes. These three types of current are: Alternating current (AC) Direct current (DC) Pulsatile current (PC)

Low frequency stimulating current (Faradic type current)

A faradic type current is a short duration
interrupted direct current with a pulse duration/length of 0.1-1 ms. Its frequency of 50-100 Hz (hertz) or 50-100 pulses per second. Its type are surged in shape Faradism was first produced by a faradic coils which was uneven in nature. First low intensity and long duration, Second high intensity and short duration.

Low frequency stimulating current Original faradic type current

Low frequency stimulating current modified Faradic type current)

Low frequency stimulating current modified Faradic type current

Physiological effects of faradic-type current

The tissue of the body is a good conductor
because of tissue ions Muscles are good conductor due to blood supply while fat is foor conductor. Current is easily travel through a low resistance rather than a high resistance Passage of current may result chemical changes

Physiological effects of faradic-type current

Stimulation of sensory nerve
The feeling of prickling sensation is due to the
stimulation of sensory nerve and this sensory stimulation causes a reflex vasodilatation of superficial blood vessel

Stimulation of motor nerve

Faradic stimulation cause contraction of that
nerve supplied muscle

Physiological effects of faradic-type current

Effect of muscle contraction
When muscle contracts due to electrical stimulation the
same changes occur ( as voluntary contractions perform) 1, increased of metabolism 2, increased the demand of oxygen and foodstuffs, 3, increased output of waste products, 4, increased metabolites which cause dilatation of capillaries and arterioles increased blood supply to muscles 5, muscle pump action increase venous and lymphatic drainage .

Physiological effects of faradic-type current

Stimulation of denervated muscle The faradic type current is unbearable by the
patient in the denervated muscles and not recommended. Chemical effects of faradic type current When the current passed through the tissues chemical changes take place at the electrodes (acid under anode & alkali under cathode) which caused electrolytic burn

Indications of faradic type current

Facilitation of muscle contraction Re-education of new muscle action Training of the new muscle function Neurapraxia of a motor nerve improved venous & lymphatic drainage Prevention & loosening of adhesions Hypertrophy muscle Increase circulation

Contraindications
1,It is contraindicated in the patient of epilepsy at the

regain of neck. 2,It is contraindicated in the patient of active pacemaker around the chest wall. 3,It is contraindicated in pregnancy (around foetus). 4,contraindicated locally in malignancy. 5,contraindicated in specialized tissue like eye and testis. 6,precautionary use in local circulatory insufficiency. 7,precautionary use in local metal implant.

Treatment techniques
Preparation of the apparatus

(practical work)
Low frequency stimulator with automatic surge is used. The operator should test the apparatus by attaching leads and electrodes to the terminals. Put your hand on moistened electrodes. Gradually increase the intensity and feel the freckling sensation of the faradic current. Describe to the patient the sensation you feel, and make sure the patient can see the muscle contraction produced. If the machine is surge automatic the duration and frequency should also be tested

Treatment techniques
Preparation of the apparatus
The active electrode may be disc electrode or a
small lint pad with a flat metal electrode. The indifferent large flat metal electrode covered by 8 layers of lint cloth with no creases for completing the circuit. The electrodes lint cloth will be soaked in warm 1 % saline or tape water to lower the resistance of the skin. The metal electrodes should be 1 cm smaller then the lint pad and should be rounded edges to prevent chemical action cause burn of tissues

(practical work)

Preparation of the patient

Clothing is removed from the area to be treated in a

good light. Patient should be in a comfortable and supported position. Climate should be worm otherwise muscle contraction will be not respond well. Adopt easiest position for the required muscle contraction. for re-educate new muscle action, put the patient in the desirable position. The Skin are high resistant for electric current so wash with soap and water for removing natural oils. The indifferent pad should firmly bandage or strapped

Preparation of the patient

The indifferent pad should be cover by
plastic sheet to avoid moistened the patient cloth. The indifferent pad should be large to avoid the current density.

Sinusoidal current
Sinusoidal current is an evenly alternating,
low frequency current. Phases of each cycles are the same intensity and duration. The frequency is usually 50 cycles, which provides 100 stimuli per second

PHYSIOLOGICAL EFFECT OF SINUSOIDAL CURRENT

STIMULATION OF SENSORY NERVE When the sinusoidal current is applied to
the body a marked prickling sensation is experienced in the sensory nerve ending which cause reflex vasodilatation. Due to vasodilatation more blood rush to skin, cause erythema.

PHYSIOLOGICAL EFFECT OF SINUSOIDAL CURRENT

STIMULATION OF MOTOR NERVE Sinusoidal current stimulating the motor
nerve cause contraction of the same nerve as tatanic of 50 cycles per second. Mostly such type is unbearable and modified as surged for contraction purpose For motor nerve contraction the sinusoidal has the same effect as FARADIC type.

PHYSIOLOGICAL EFFECT OF SINUSOIDAL CURRENT

Effects of muscle contraction increased
metabolism, improved blood supply, increased venous and lymphatic return and developed muscle bulk. Effect on denervated muscle not tolerated by the patient. Chemical effect is not possible because phases are evenly changed.

Therapeutic effect of sinusoidal

Physiological effect of the faradic and sinusoidal
are similar, but therapeutically faradism are suitable in some cases and sinusoidal is the current of choice in some other. Sinusoidal current can satisfactorily be applied in baths when generalized effect is required. Facilitation of muscle contraction Re-education of muscle action. the brain appreciates movement s, not muscle action, so the current should be applied in such a way that it causes the movement that the patient is unable to perform.

Therapeutic effect of sinusoidal

Training of new muscle action. After tendon
transplantation, or other reconstruction operation, a muscle may be required to perform a different action from that which it previously carried out. Exercise for paralyse muscles. When due to some reason of peripheral nerve paralysis, stimulate the muscle below the site of the lesion to keep them in a good condition until the nerve begins to conduct impulses again.

Therapeutic effect of sinusoidal

Strengthening and increased bulk of muscle. Increase in blood supply. Improved venous and lymphatic drainage.
Sinusoidal baths may be used for mild cases of oedema. faradism or sinusoidal under pressure and is used in the treatment of treatment of oedema. Counter-irritation. the sinusoidal current may be used to relieve pain by counter-irritation as the sensory nerve conductivity is reduced

Stimulation of the motor points

This method has the advantages of stimulating of individual

muscle contraction. The optimum contraction of each can be obtained. It may therefore be selected when action of new muscle is required. The apparatus and patient should be prepared as previously describe. The indifferent electrode is applied and secured in a suitable area. The active electrode may be disc electrode and hold in between the index finger, middle finger with the support of the thumb.

Stimulation of the motor points

It is placed on the motor point to be stimulated firmly firm contact ensure minimum discomfort. A suitable duration and frequency of surge must be
selected. The intensity of the current are gradually increase for a visible contraction follow by relaxation of the muscle The duration of the treatment should not exceed to fatigue the muscles. We introducing the motor points for batter response.

Motor point of the facial nerve

Approximate motor points of the anterior aspect of arm

Approximate motor point of hand

Some of the motor points of Posterior aspect of the right arm

Some of the motor points of Posterior aspect of the right hand

Some of the motor points of anterior aspect of the leg

Some of the motor points of Posterior aspect of the leg

Some of the motor point of the back

Stimulation of the group of muscles

Stimulation which makes all the muscles
of a group work together is a satisfactory method of re-educating the action of a muscle. Which normally as a group, such as the quadriceps, small muscles of the foot, and the muscles of the pelvic floor.

Stimulation of the group of quadriceps muscles

Stimulation of the group of lumbrical muscles

Stimulation of the group of muscles

Electrical diagnosis
When there is disease or injury of the
motor nerve or muscle alteration are liable to occur in their response to electrical stimulus. this alteration of electrical reaction may be of considerable value in the diagnosis of the lesion of nerve or muscle. Reduction or loss of voluntary power of a muscle may be due to; (continue)

Electrical diagnosis
1. 2. 3. 4. 5.
A lesion of the upper motor neuron. A lesion of the lower motor neuron. Damage of the muscle itself. A fault at the neuromuscular junction. A functional disorder. The lower motor neuron below its exit from the vertebral canal and the muscle itself are normally accessible to electrical stimulation.

Electrical diagnosis upper motor neuron

In the upper motor neuron lesions there
are no change occur in the lower motor or the muscle,-----which altered electrical reaction---- so you will be obtained normal response to electrical stimulation. Some times the nerve or muscle are hyper exitable and react to alower intensity of current than that normally required.

Electrical diagnosis lesion of lower motor neuron

Damage to a lower motor neuron may
involve either the anterior horn cell. Or the fibers of the roots. Or peripheral nerves. Lesions involving the nerve fibers can be classified into three groups; like Neurapraxia:: Axonotmesis:: Neurotmesis

Electrical diagnosis lesion of lower motor neuron

Neurapraxia It is a 1st degree degeneration in which
pressure or bruising on the nerve incapable of conducting impulses from the site of the lesion. The damage is not sever enough to cause degeneration of the fibers. During testing the affected muscle normal response is obtained, but there is loss of response to a stimulus applied to the nerve trunk above the lesion.

Electrical diagnosis lesion of lower motor neuron

Axonotmesis
It is the 2nd degree degeneration of the nerve if
the lesion is more severe. Axonal degeneration takes place but the sheath of the nerve remaining intact. For example Saturday night palsy. Once the nerve fibers have degenerated, alterations in the electrical reaction occur.

Electrical diagnosis lesion of lower motor neuron

Neurotmesis
It is the 3rd degree of degeneration of the nerve, The same alteration seen as in Axonotmesis
below the site of the lesion. Mostly nerve sheath and axons are degenerated Regeneration with out suturing of the nerve have no fruitful result. Anastomosis is the suturing of the nerve end to end.

Defect in the neuromuscular junction

Occasionally, as in the disease myasthenia gravis
reduction of voluntary power is due to faulty conduction at the neuromuscular junction. Need to be diagnosed properly rather than the stimulation. The deficiency of Acetylcholine receptor; Acquired
autoimmune disorder which is clinically characterized by;; Fatigability on exertion and weakness of skeletal muscle.

Itself muscle disease; The lesion of the muscle is so severe

that there is complete loss of muscle tissue.

Functional disorder; due to hysterical paralysis, in which there

is no alteration in the electrical reaction

Stages of degeneration
Walla rain degeneration;
This degeneration takes place with in the
14 to 21 days. Before this period reaction of the electric will be not prominently change and will indicate false report. For more accurate report wait for this period.

Strength duration curve

The plotting of strength-duration curve, which
indicate the strength of impulses of various durations required to produced contraction in a muscle. The advantages of this method of testing indicates the de-nervation to the muscle. The test never indicate the site of the lesion. Lesion will be determined on test of the nerve conduction of the affected side. The test need very thoroughly skill for evaluation the site and location of the lesion.

The apparatus used for SDC

The apparatus for obtaining SDC supplies
rectangular impulses' of different duration. Both the form and duration of the impulses must be accurate. The apparatus should be checked at regular intervals to ensure satisfactory working. Impulses with duration of 0.01, 0.05, 1, 3, 5,10,30,100,300,ms are required. IDC,or surged faradic are best to perform.

SDC of Normally innervated muscle

Partially denervated muscle

SDC for completely denervated muscle

Partially denervated muscle

Plotting of the SDC in different period

SDC of the abductor digiti minimi in a
recovering ulnar nerve lesion; 40,70,139, 160,280 days after suture.

Plotting of the SDC in different period

Other tests of electrical reaction

There was some other test in the past
which is now not in a prectical life however some of the tests; Rheobase it is the stimulus to a muscle with a long duration so the current will be less. Chronaxie it is the stimulus to a muscle with a short duration so the current will be double of the rheobase.