Patient Care 1 Exam 3 Study Guide – Osantowski

Terms Definitions
Potential the flow of current in a medium such as the charge-carrying ions in electrolyte solution
Repolarization is the restoration to resting potential
Refractory Period refers to that time period when the nerve is unexcitable to another stimulus, regardless of intensity
Orthodromic In the direction of “normal” propagation. In normal physiological stimulation, propagation occurs in
ONLY one direction, depending on the type of nerve fiber
Antidromic Propagation in the direction OPPOSITE to the normal physiological direction
Direction of Action In clinical e-stim, action potentials evoked in peripheral nerve are transmitted along the nerve fiber in
Potential Generation in BOTH directions from the point of initiation. Conduction is towards the periphery in sensory nerve
Peripheral Nerve fibers and toward the CNS in motor nerve fibers
Frequency (Hz/pps) Represents the rate at which something occurs or is repeated over a particular period of time; in e-
stim the number of pulses/second. Determines what the patient will feel such as “tapping or pins and
needles”
Adaptation Neural adaptation or sensory adaptation is a change over time in the responsiveness of the sensory
system to a constant stimulus. It is usually experienced as a change in the stimulus. The sensory
neurons that initially respond are no longer stimulated to respond; this is an example of neural
adaptation. This can be over come by altering the stimulus with modulation of frequency, amplitude
or pulse duration.
Noxious stimulation irritating or painful feeling to the patient. The intensity of the stimulation is so high that many A delta
and C nerve fibers (carry pain signal) are activated.
Duty Cycle The ratio of on-time to the total cycle time (on + off time)
On/Off time (ratio) When stim is on, muscle contracts, during off-time the muscle relaxes
Rise Time/Decay Time Time to peak and time back to zero current
Ramp Up/Ramp Down Time to reach maximum amplitude and time to return to zero (used to prepare neuromuscular tissue
for electrical current)
Monopolar Different electrode pad size (smaller active pad over motor point and the large dispersive pad over
distal or proximal muscle)
Bipolar Same electrode pad size, placed at opposite ends of the muscle
 Patient Care 1 Exam 3 Study Guide – Osantowski

Current density Amount of current flow per cubic volume or surface area
Motor Point A point on the skin that stimulates proximity to superficial peripheral nerves and is an option for
effective application for stimulating muscle contraction
Rheobase Minimum current amplitude required to produce action potential (Measure of amplitude)
Chronaxie Minimum duration to stimulate at twice rheobase intensity (Measure of time/duration). The
significance is that e-stim machine manufacturers use chronaxie to establish present PD values.
Amplitude Modulation Variation in peak amplitude in a series of pulses or cycles (voltage)
Phase/Pulse Duration Variations in PD in a series of pulses
Modulation
Frequency (rate) Variations in frequency in a series of pulses
Modulation
Ramping (surge) Cyclical, sequential increase/decreases in phase charges over time
Modulation
Timing Modulations Variations in delivery patterns of a series of pulses or cycles of alternating current
Constant Current Produce a constant current independent of resistance encountered. The voltage adjusts to maintain
Stimulators constant current flow. The advantage of this type of stimulator is to ensure a consistently physiologic
response during the treatment. The negative is potential pain when the voltage increases to
overcome resistance.
Constant Voltage Conversely, produce a constant voltage. The current adjusts, depending on changes in resistance.
Stimulators This feature is advantageous in preventing discomfort with changes in resistance, such as an
electrode losing full contact, but quality of response can be decreased with these automatic
resistance changes.
Carrier Frequency The stable, unchanging frequency of the base channel for interferential electrical stimulation.
Beat Frequency Frequency of when the interfered currents are maximally in-sync, noted as a sensory experience by
the patient. This determine the physiological effect.
Sweep Modulation of the beat frequency. The beat frequency varies between the maximum and minimum
settings established in the set-up parameters (80-150 beats/second)
Vector scan Amplitude modulation of the input currents. This is experienced as a migrating sensory pattern by
the patient.
Phoresis A biological association in which one organism is transported by another
 Patient Care 1 Exam 3 Study Guide – Osantowski

Current: Direction: Used for: Types of E-Stim Presets

Direct Current
Alternating Current
Pulsed or Pulsatile Current
Continuous unidirectional Wound healing, denervated muscle, IONTO
decrease edema Microcurrent
Continuous bidirectional Decrease pain, decrease spasms, Russian
decrease edema, Increase strength Portable units/biphasic
IFC
Pre-modulation
Biphasic Symmetrical
Biphasic Asymmetrical
VMS
Discontinuous HVPC
uni/bidirectional

Indication Type Waveform Pulse Pulse Amplitude Duration

Frequency Duration
Muscle NMES Biphasic PC 50-80 pps 200-800 As high as 10-20 strong contractions
strengthening or burst- or bursts μsec tolerated with a
modulated per sec goal of reaching Things to Consider When Applying NMES:
AC more than 60%-  Line or battery-powered stimulator
(Russian) 70% maximal  Stimulation parameters
voluntary  Electrode placement
contraction  On and off times
(MVC)  Dosage (intensity)
 Number of repetitions/sets
 Frequency of Application
Muscle FES Biphasic PC 20-60 pps 200-800 To level Task specific (standing, walking, reaching or
contraction or burst- or bursts μsec commensurate used during amb with AD or with exercise
for functional modulated per sec with functional machines)
use AC activity
(Russian)
 Patient Care 1 Exam 3 Study Guide – Osantowski

Name: Electrode Location: Common Use:

Monopolar Active electrode of single circuit over target area; Pain modulation, IONTO, tissue healing
inactive over nearby nontreatment area

Bipolar Both or all electrodes of single circuit over target Muscle activation, pain modulation
tissues

Condition Type of e-stim to use for specific condition:

Pain modulation Conventional, acupuncture-like, brief intense, burst mode, IFC, Pre-Mod, portable TENS units
Muscle contraction Russian or Symmetrical Biphasic

Wound healing HVPC, DC

Edema Motor response level – pump fluid out
HVPC/DC – using negative polarity to pump fluid out

Details about portable TENS Modes:

Conventional: short duration, high frequency, amplitude sensory
Acupuncture-Like: long duration, low frequency, amplitude
sensory/motor
Brief-Intense: long duration, high frequency, sensory/motor amplitude
Burst: low frequency burst, sensory/motor
Modulation: variable PD, frequency, amplitude
 Patient Care 1 Exam 3 Study Guide – Osantowski

Electrical Stimulation

Indications: Precautions: Contraindications:

 Pain control  Impaired sensation  Cancer

 Muscle  Cognitively impaired patients  Eyes, mouth, trans-cranially,
weakness/denervated/atrophy  Adverse reaction to the external gonads
 Tissue healing application of e-stim  Desensitized areas
 Wounds  Sensitivity to drugs (IONTO)  Broken skin
 Edema control  Freckles  Over cardiac pacemaker
 Muscle re-education  Fair skinned person  Carotid bodies/sinus
 Muscle relaxation  Sensitivity to adhesive  Phrenic nerve
 Transdermal Drug Delivery  Heart arrythmia  Peripheral vascular disease
 Increase peripheral blood flow  Over menstruating uterus  Pregnancy – over uterus
 History of epilepsy
 Patient Care 1 Exam 3 Study Guide – Osantowski

Types of E- Used for: Waveform Pulse Frequency: Amplitude: Tx Time and Duration: Additional info:
Stim: Duration:

IFC Pain modulation Amplitude 200-400 μsec 100 Hz Sensory level: 1- 10-30 mins Can place the
modulated 100 mA electrodes using
AC the Bipolar method
or Quadripolar
method

Pre- Pain modulation Amplitude 200-400 μsec 100 Hz Sensory level: 1- 10-30 mins
Modulation modulated 100 mA
AC

TENS Pain modulation Pulsed, 50-400 μsec 1-200 Hz 0.1-120 mA Can last minutes to Can use a single
biphasic hours or double channel
balanced, Can run current in
AC parallel or cross to
cover a larger area
 Patient Care 1 Exam 3 Study Guide – Osantowski

Types of E- Used for: Waveform Pulse Frequency: Amplitude: Tx Time and Duration: Additional info:
Stim: Duration:

Russian Muscle contraction Burst- 200-800 μsec 30-100 Hz To maximal 10 sec on/50 sec off Monopolar or
with high motor modulated contraction for (Can vary and be 5/5, bipolar
unit recruitment AC Phase strengthening/end 10/10, 10/30)
duration: half urance (NMES) Optimal placement
of pulse Ramp up: 1-2 sec is over a motor
duration Ramp down: 1-2 sec point

Symmetrical/ Activation of Symmetrical 200-800 μsec 20-60 Hz FES: to level for FES: activity dependent
Asymmetrical skeletal muscle for biphasic: functional use NMES: 1-2 sec
Biphasic strengthening and square or NMES: to
endurance triangular max NMES: 10 sec on/ FES ramp up/down:
(NMES), or contraction for 50 sec off activity dependent
functional strengthening/
electrical endurance NMES ramp up/down:
stimulation (FES) 1-2 sec
High Volt Pain modulation Twin-peak 40-100 μsec 60-125 Hz Sensory level: to Sensory level: 10-30
(HVPC) Wound/tissue monophasic perceivable level mins
healing pulsed DC
Edema Motor level: to Motor level: 1-30 mins
visible motor
response

Microcurrent Wound/tissue Low intensity 0.5 msec or 1 Hz 10 - 600 A Minutes to hours

(MENS) healing DC DC

Iontophoresis Inflammatory Continuous Intensity of current Treatment delivered in Depending on the

musculoskeletal monophasic based on patient drug delivery doses type of ions being
conditions current, DC tolerance (1.0-5.0 based on current and delivered, anode or
Used for an mA) time (4.0 mA x 10 cathode is placed
analgesic effect Considerations for minutes = 40 mA-min over the treatment
Wound healing selecting amp: dose) area 5. Active
Edema reduction  Patient Three ways for delivery: electrode pad size
Hyperhidrosis tolerance based on area
 Patient Care 1 Exam 3 Study Guide – Osantowski

 Polarity of Electro-repulsion: Same being treated and

active charges repel delivery needs.
electrode Electro-poration: E-stim Passive
 Size of active increases superficial (dispersive)
electrode skin electrode should
Duration of porosity/permeability, be larger than
treatment creates openings in the active and placed
skin for drug passage adjacent to active
Electro-osmosis: pad.
Attraction of H20 and
Na+ towards cathode
pulls medicine ions
through

Biofeedback:
 Can have auditory or visual stimulus for the patient/therapist
 Does NOT involve delivery of electrical current
o Picks up electrical signals from the muscles you are treating
 Can be used to teach patient how to relax and reduce tension (kinesthetic awareness of motion)
o Used in pain control
o Alarm mode use
 Facilitate or inhibit muscle contraction:
o Facilitate:
 To increase muscle activity after surgery or injury when volitional recruitment is impaired
 To normalize the balance of muscles acting at a joint where one muscle group may be insufficient
 To improve volitional motor control following dysfunction of the CNS
 To increase volitional control of pelvic floor muscles for rehabilitation of urinary incontinence
o Inhibitory:
 To help decrease activity in muscles demonstrating spasticity caused by dysfunction of the CNS
 To help decrease activity in muscle demonstrating increased activity caused by postural stress or
anxiety
 To help decrease muscle activity associated with chronic pain
 Can be used to make patients feel more comfortable receiving e-stim for muscle activation
 Patient Care 1 Exam 3 Study Guide – Osantowski

Key Points:

Sensory Level:
 Pulse duration is between 20-100 μsec
 Frequency (pps) is low
 Adaptation can occur, but if you interrupt this by modulating the amplitude, pulse duration or frequency, then
adaptation is reduced.

Motor Level:
 With increasing intensity, greater numbers of sensory nerve fibers are recruited. Eventually, activation threshold for
alpha motor neuron axons lying in peripheral nerves innervating skeletal muscle is reached.
 Pulse duration is between 100-600 μsec
 In voluntary contraction, motor units are recruited from smallest to largest as the requirements for force are
increased.
 In stimulated contraction, recruitment is opposite. So, fast twitch motor units are recruited first, followed by slow
twitch (fatigue resistant), unless slow twitch are closer to the stimulating electrode.

Current Density:
 is highest at skin and decreased in deeper tissue
 is superficial when electrodes are placed close together and deeper when electrodes are farther apart
 with unequal sized electrodes, the current density beneath the small electrode is greatest and felt by the patient
 can change as an electrode pad is removed and the unit is still on

Current intensity
 Sensory: lower mA amplitudes
 Motor: higher mA amplitudes

Pulse Duration
 Sensory stimulation: < 80 μsec
 Muscle contraction: 150-350 μsec
 Denervated muscle: > 10 msec
 Patient Care 1 Exam 3 Study Guide – Osantowski

Electrical Stimulation:
 Fast twitch first, then slow twitch
 Fast twitch = high fatigability
 Rapid and jerky contraction when stimulus reaches threshold
 Produces overload to maximize strength gains
 Greater post-exercise muscle soreness (PEMS)

Frequency:
 DOES NOT determine whether or not a response will occur, nor does it determine whether the response will be
sensory, motor, or noxious
 Frequency effects the pattern or quality of the response
 Sensory stim:
o tingling, tapping
 Motor stim:
o a twitch (a few pps)
o a sustained contraction (greater pps)
o tetany (even greater pps)

Resistance:
 Body tissues vary in their resistance.
o higher resistance tissues heats more when the electrical current is passed through it
o If the initial resistance of skin is reduced, then the current flows more easily
o Blood and muscle have low resistance and are good conductors
o Bone and tendon have higher resistance and produce heat with electrical stimulation
 Measured in Ohms
 Ohm’s Law: In an electrical circuit, the flow of current (amperage) is in direct proportion to the electromotive force
(voltage) of the generator and inversely proportional to the resistance of the circuit.

Effect of e-stim:
 Thermal: all electrical currents cause a rise of temperature in a conductor due to conversion of electricity into heat.
o The heat production is in accordance with Joule’s Laws:
 The heat produced is directly proportional to the square of the current strength.
 Patient Care 1 Exam 3 Study Guide – Osantowski

 The heat produced in different conductors is directly proportional to the resistance (opposition to flow
of charged particles) of each conductor.
 The resulting quantity of heat is in direct proportion to the duration of the passage of the current.

 Electromagnetic:
o Corresponding to a force effected by a current on a magnet, there is a reciprocal action of a magnetic field
upon a current.

 Chemical:
o When direct current is applied to an electrolyte solution the ions wander; positively charged ions are
attracted toward the negative pole (cathode) and negatively charged toward the positive pole (anode).
Accumulation of ions cause a change in pH in the tissues, either causing an acidic (<7) or alkaline (>7) build
up.

 Vascular:
o Muscle contraction may cause increase in blood flow or rhythmic assist to venous lymphatic flow.
o Variables affecting the vascular response are:
 the stimulation site
 stimulus characteristics (pulse duration, charge, total current, on/off times, polarity)

Things to Remember/Common Errors:

 Prep the skin properly to reduce inherent resistance
o Don’t use alcohol wipes, soap and water better
o Make sure there is minimal hair, but don’t shave the patient and perform treatment the same day, ask them
to shave and come back in 3 days
 Make sure the pads are completely plugged into the lead
o Could result in shocking or burning the patient
 Make sure electrode pads are not peeling away from the patient
 Do not take the electrodes off the patient while the machine is still on
 Make sure the lead is plugged into the correct channel you are using
 Do not turn up the intensity during the off time