EPA summary

Heating
Physio effects: skin vasodilation -> erythema, edema (dep on amt), incr cellular rxn
rate, protein denat > 40 deg, incr flexibility of collagen, decr fluid viscosity, decr
muscle tone (decr firing rate of muscle spindle + GTO), sedative effect (gating mech stim of mechanoRs)
o Incr tissue repair w 1-2 deg, incr O2 avail+ cell/mediator [ ],
o incr jt ROM 4-5 deg from collagen flexibility + decr tone + incr synovial slide =
good for incr ROM
o incr growth of bac
indications: pain (gating), muscle spasm (decr reflex activity), chronic inflamm (incr
perfusion), contracture (incr flexibility), subacute/chronic injury
Contraindications/precautions: cognitive deficit, morbid obesity, open wounds,
loss of sensory discrim, allergy to cold/hot, tissue ischemia, dermatitis,
hypersensitivity, cryoglobinemia/hemoglobinuria
Cooling
Physio effects: vasoconstriction + vasodilation = mottling, decr edema from decr
vasc perm + decr release of vasodilators, decr metabolism = decr need for O2 ->
decr risk of 2ndary tissue hypoxia, decr flexibility of collagen, incr fluid viscosity, decr
sensation, decr muscle tone
o decr hemorrhage, delayed tissue repair due to decr O2 avail, decr jt ROM,
reduced muscle strength
o Use after injury to prevent secondary injury
o Acute injury: decr swelling, decr pain, prevent 2ndary hypoxic injury, incr
clotting
o Subacute/chronic: decr healing rate, decr motor F, decr absp inflamm, incr
stiffness (bad)
Indications: pain, muscle spasm, acute injury (control bleeding, decr edema)
TENS
Indications:
o Acute: from MSK, post-surg, CRPS, neuralgia, facial pain, headache, reflex
muscle spasm
o Chronic: spinal origin, neuralgia, CRPS, OA/RA, hemiplegic shldr syn
o Conditions: autonomic dysfxn, stages I/II labour, abs of inflamm, wound and
bone healing, neuropathic pain (diabetes), cancer rel pain, nausea
C-TENS: targets skin aff/large d n + opioid R, high freq (80-120 Hx) pulse duration
150-200 us
o Amplitude/intensity = strong + subnoxious to max tolerable < 15 mA
o Duration = pain relief during Rx but disappears 0-20 min post
o Physio effects: activ mechanoR -> pre-synaptic inhib from inhib interneuron,
delta opioid agonist?
A-TENS: target large diameter a-MN, Adelta + C fibers, mu opioid R, low freq (3-5
Hz), 250 us pulse
o Amplitude = forceful non-painful muscle twitch
o Duration = 30 min; repeated every 4 hrs as necessary
o Physio effects: activ muscle spindle -> ascending pathway -> activ desc inhib
-> opioid release
Burst TENS = combo of both

IFC

Contraindications: pacemaker, over heart if pts have cardiac probs, over carotid
sinus or DVTs, malignancy, infxn areas, pregnancy abdomen or lumbar spine
Precautions: loss of skin sensation (don't treat after ice), obesity, damaged
skin/open wounds, skin allergies, elderly or children
Negative outcome factors: stabbing or pulsating pain, unmod/intractable pain,
pain at diffuse or multiple locations, analgesic abuse, depression, multiple Sx for pain
Phase/pulse duration fixed 4000 Hz for 125 us
Physio effects: stim of sensory and/or motor n, release of opioids, incr PM perm =
incr ionic + cell activity -> incr growth + repair, may inhibit bac growth
o Decr pain gating, desc path, direct block of nociR, removal of metabolites,
placebo
o Decr swelling/inflamm inc removal, incr perm, activ of motor n -> muscle
pump
o Decr in stress incontinence and urinary freq
Targets AB mechanoR, Adelta (sharp pain), C fiber (aching pain)
Parameters:
o Pain relief: constant = 50-100 Hz (gating) < 10 Hz for desc
Variable = high 80-200 or full 1-200 (gating), 1-10 Hz (desc)
o Decr swelling/inflamm: constant = > 100 Hz (decr SYM) 30-50 (muscle pump)
Variable = 1-200 (incr perm, pump, flow) or 1-10 (incr perm)
o Incr muscle contraction: constant 30-70 Hz
Contraindications: pacemakers, over carotid sinuses/heart/DVT, malignancy, within
10m diathermy unit, near bladder stimulators, over areas of infxn, abd/pelvic/lumbar
in preg, head/neck if seizures, over an area with lack of intact sensation

Ultrasound
Increased density of tissue = incr absorption of E
Parameters:
o Frequency: 1 MHz for deeper, 3 MHz for superficial
o Intensity: lower BNR = more uniform (SP/SA)
o Continuous vs pulse: 1:1 = 50% duty cycle, 1:4 = 20%; SATP = SATA for
continuous
Rx = U/S, 3 MHz, 1.0 W/cm2 SATP, 20% duty cycle x 10 min + area
Thermal U/S: 3MHz = more superficial heating, incr blood flow, incr metabolism, incr
collagen flex
o Indications: decr pain (mild), fibrotic conditions (40 deg)
o Inefficient to treat areas > 10 cm2
o Parameters: 0.8-2.0 W SATA continuous according to body comp (lower if
superficial, higher if deep to large muscle of fat layer), 1 MHz for depth > 1.6
cm; 10-15 min
Athermal U/S: tissue repair, drug delivery, accelerate process of inflamm, align
collagen + incr amt, incr wound contraction, vasodilation in ischemic areas
o Parameters: pulsed 1:4, 0.5-1.0 W SATP; 3 MHz for skin lesions, 1 for deep, 15
min per 10-15 cm SA, 5x/wk for 2-3 wks -> 3x/wk 2-3 wks
Chronic conditions SATP 2.5 W 15 min
o Wounds: 3 MHz, 1:4, 1.0 SATP/0.2 SATA, 5 min per 2.5 cm2 area + 1 min for
each additional 0.5 cm of wound area; 3x/wk until healed

Contraindications: on eyes, over abd in preg, on testes, over malignancy or

vascular insuff, over heart, lack of sensation, infxn/sepsis, where bleeding is
occurring/could occur, unreliable pts
Precautions: always move applicator, use lowest intensity that can produce
therapeutic response, caution over implanted electronic devise, caution over
superficial metal implants, avoid over plastic jt implants

Laser
Indications: wound healing, bone regn and fracture healing, epicondylitis,
tendinopathy, carpal tunnel syndrome, arthritis
Longer wavelength + lower freq = more penetration than shorter wavelength/high
freq
o Penetration reduced with incr body fat or melanin = incr ED (PD x t)
o E reaching body highest when E output high, laser close to body, beam
perpendicular to skin
Effects: incr ATP syn, incr tissue healing, promotes collagen prod, mod inflamm,
vasodilation, incr/decr nerve conduction v, incr freq APs, dec/inc distal sensory
latencies, inc n regen, decr n scarring, axonal sprouting, incr wound closure, incr
tensile str wound, incr collagen [ ], acc inflamm/prolif/mat phases
Parameters:
o 10-300 Hz: sedative effect pain mgmt
o 1000-5000: stim effect inflamm conditions, wound healing
o 10000-30000: fibrolytic effect chronic tendonitis
Contraindications: over eye, over abd in preg, malignancy, acute hemorrhage,
hypersens to light, epilepsy/seizures, DVT, immunosupps, over cervical plexus, over
pacemaker, unreliable pts
NMES
Reversed recruitment IIb -> IIa -> I or without sequencing; all or none, synchronous
= strong, painful, only concentric contraction
Parameters: rate 30-70 pps (higher for larger muscles), on time 2-5 sec (small) or 510 (large), off time 3-5x longer than on, ramp up 1-2 sec, ramp down 0-1 sec
Effects: fac motor unit recruitment in weak muscle, fac strengthening, reduces
spasticity effects , temp orthotic sub, decr effects of disuse atrophy, fac muscle reeduc
Application:
o 1 channel: one on motor pt, other prox/distal to motor pt OR goes goes on n
that innerv muscle
o 2 channels: one or more on motor pt(s), others are prox/distal to motor pt or
cover muscle belly
Contraindications: pacemakers, over carotid sinuses or heart, near DVTs,
malignancy, 10m of diathermy, near bladder stimulators, over areas of infxn,
abd/pelvic/lumbar in preg, head/neck if seizures, over an area with lack of intact
sensation
Precautions: while operating MVs or dangerous equip, osteoporosis, obesity