1. Ultrasound
   1. Definition
      1. Acoustic energy (sound waves) used to help restore and heal soft tissues
   2. Deep-heat modality
   3. Physical principals
      1. Generator produces a frequency at 1-3 MHz
      2. longitudinal wave
      3. shear wave
      4. standing wave
   4. Energy distribution
      1. The frequency of the ultrasound determines the depth of penetration and rate of heating
      2. Beam nonuniformity ration (BNR) - intensity of the beam of energy
      3. Duty cycle - a percentage or ratio of time the ultrasound energy is being introduced to the body
   5. Effects on tissue
      1. Thermal
         1. Increases extensibility of collagen fibers
         2. Decreases muscle stiffness
         3. Reduces muscle spasm
         4. Alters nerve conduction velocity/diminishes pain perception
         5. Increases metabolism and blood flow
         6. Increases metabolism and blood flow
         7. Provides all of the effects of nonthermal ultrasound
      2. Nonthermal
         1. Increases phagocytic activity of macrophages/attracts immune cells to tissue
         2. Increases protein synthesis
         3. Increases capillary density
         4. Regenerates tissue
         5. Heals wounds
   6. Phonophoresis
      1. use of ultrasound to facilitate the delivery of topically applied drugs of medication to selected tissue
   7. Precautions
      1. Unhealed fracture sites
      2. early stages of tendon or ligament repair
      3. osteoporosis
      4. plastic and medal implants
   8. Contraindications
      1. DVT
      2. Bleeding and edema
      3. Sensation loss
      4. Pregnancy
      5. Infected areas
2. Electrotherapy
   1. Frequently used applications
      1. NMES
         1. Pulsating, alternating current to activate muscles through stimulation of peripheral nerves
      2. FES
         1. Electrical stimulation to activate targeted muscle groups for orthotic substitution or to facilitate fx activities
      3. TENS
         1. Uses surface electrodes to control pain as a sensory analgesia
      4. EMS
         1. electrical stimulation of denervated muscle to facilitate viability and prevent atrophy
      5. IFC
         1. utilizes two channels simultaneously with different frequencies
   2. Principles of electricity
      1. Current
         1. movement of ions or electrons from one point to another to equalize the charge
         2. Types
            1. Direct current
            2. Moves in one direction
            3. Pulsed current
            4. electron flow is periodically interrupted for very short periods
            5. Alternating current
            6. periodic changes in the polarity of the current
      2. Duration
         1. The length of time between the beginning and end of one phase of the pulse
      3. Stimulus Frequency
         1. The number of pulses or wave forms repeated at regular intervals
      4. Duty cycle
         1. The proportion of time between the stimulation period and the rest period
      5. Modulation
         1. Changes to the current or to the pulse characteristics
      6. Ramping
         1. A change of the pulse intensity of duration of the current
   3. Physiology of nerve and muscle excitation
      1. Propagation
      2. Electrically stimulated movement
   4. Treatment Planning
      1. Electrodes
         1. Electrode size
            1. Current density is inversely related to the electrode size
         2. Placement
            1. Placed closer together, the current passes superficially
            2. Placed further apart, the current passes deep
      2. Neuromuscular Electrical Stimulation
         1. Maintain Muscle Mass
         2. Maintain or gain range of motion
         3. Management of Spasticity
         4. Facilitate voluntary control
      3. Functional electrical stimulation
         1. acts as a replacement for orthoses
      4. Transcutaneous electric nerve stimulation
         1. Pain
      5. Iontophoresis
         1. topically delivering medications