Medical Vital Signs

This medical examination routinely did and monitored by healthcare professionals to help assess the general health of a person. Vital signs are useful in detecting or monitoring medical problems. The normal ranges vary with person to person, age, weight, gender, and overall health. The four primary vital signs include:

• Body temperature
• Pulse rate (Heart rate)
• Respiration rate (rate of breathing)
• Blood pressure

English: Pulse evaluation Deutsch: Pulstastung (Photo credit: Wikipedia)

I.  Body temperature

The temperature obtained through a thermometer.  The temperature measured in either degrees Celsius (C) or degrees Fahrenheit (F). The normal body temperature can range from 97.8 degrees Fahrenheit to 99 degrees F, equivalent to 36.5 degrees C to 37.2 degrees C. The normal body temperature of a healthy person varies depending on gender, recent activity or exercise, the time of the day, and during menstrual periods in women. Usually an elevated temperature (in a fever) indicates signs of systemic infection or inflammation. 
Body temperature is usually taken in any of the following methods:

Oral

It is by mouth placed under the tongue using either a classic glass thermometer or a digital thermometer that uses an electronic probe to measure body temperature. This method is the preferred among adults.

Rectal/Anal

The temperature taken rectally using a glass or a digital thermometer. The thermometer inserted in the anus about 1 inch. The anal reading is 1 degree higher because it is higher than the core temperature compared to the oral method. This method is the preferred among children.

Axillary

The thermometer placed under the arm using a glass or a digital thermometer. The axillary reading will be 1 degree lower than those temperatures taken by mouth because it is not a core temperature reading. 

Tympanic

A special thermometer used for this reading. It goes inside the ear to obtain the body's core temperature. 

Temporal

A special thermometer used to quickly measure the temperature of the skin on the forehead and swiped along one side of the face. 

Skin

These are strips that measure the patient's temperature. This method used when there is no other way to get the temperature reading available because the accuracy in not good. 






II.  Pulse Rate

This measures the number of times the heart beats per minute (BPM). It is the physical expansion of the artery as the heart pushes blood to the arteries. Taking the pulse rate will also determine the strength of the pulse and the heart rhythm. Pulse rate increases with exercise, illness, injury, and emotions. It varies with age. Infants have higher beats per minutes compared to adults. Place the tips of your index and middle fingers just proximal to the patient wrist on the thumb side to measure the radial pulse rate.


Normal Values

• Infant: 100 to 130 bpm
• Child:  80 to 100 bpm
• Adult:  60 to 100 bpm

Pulse site

• Brachial
• Carotid
• Dorsal pedal
• Femoral popliteal
• Posterior tibial
• Radial
• Temporal
• Common sites: carotid and radial pulse site

Related Terms

• Bradycardia is a condition of a heart rate consistently  below 100 bpm. Beating is too slow
• Tachycardia when the heart is above 100 bpm. Beating is too fast
• Strong/Regular pulse indicates that there is an adequate force and consistent beats
• Weak indicates a poor force contraction
• Irregular indicates an arrhythmia. Out of normal rhythm

 

Peripheral Pulse Assessment Grading System

• 0-3 scale
• 0 absent
• 1+ weak/thready pulse
• 2+ normal
• 3+ full, firm pulse

Pulse Amplitude Classification

• 0 absent
• 1+ diminished
• 2+ normal
• 3+ moderately increased
• 4+ markedly increased

III. Respiratory Rate

The respiratory rate is the number of breaths a person takes per minute, that is an inhalation-exhalation cycle. Respiration recorded as breaths per minute. It varies with age and increases with fever, illness, or other medical conditions.  Respiratory rate indicates an acidosis condition.

Inspiration - to breathe air into the lungs
Expiration - to breathe air out of the lungs

Normal Rate

• Infant 30 to 50 respiration per minute
• Adults 12 to 18 respiration per minute

IV.  Blood Pressure

Blood pressure is the force that moves blood through our circulatory system. I have a blog post on this topic.

Nursemaid Elbow (Pulled Elbow)

This common pediatric condition refers to radial head subluxation (radiocapitellar joint of the elbow complex) generally occurring between the ages of 1 and 4 years, although it can happen anytime until the age of 7. At that age, the soft tissues, including muscles and bones still continue to develop that even a mild sudden pulling force on the extended pronated forearm produce a partial dislocation. Children at this age are very active in their play activities such that tugging a child or by swinging them around or back and forth by the arms causes the bone to slip out of its normal place at the joint.




Left elbow-joint Left: anterior and ulnar collateral ligaments Right: posterior and radial collateral ligaments (Photo credit: Wikipedia)





Causes:

• Catching a child by holding the hand or wrist to stop a fall.
• Pulling a child up by the hands or wrists to keep out of danger or lifting a child over a high step
• When an adult swing a child by holding the arms or hands.
• Quickly grabbing a child's hand or wrist to walk faster or even pulling a child hand along while walking
• Pulling a child hand through a long-sleeve jacket 
• An infant rolls over in an unusual way in a crib, bed, or in the floor

Signs and Symptoms:

• Moving the injured arm is painful, especially supination
• The child injured arm is kept on his/her side, usually held in flexion and pronation
• Minimal swelling

Differential Diagnoses:

• Elbow Fracture
• Soft Tissue, Hand or Wrist Injury
• Wrist Fracture 

Brief Anatomy:


The bone of the upper arm (humerus) and the two bones of the forearm (radius & ulna) made up the elbow complex. Medial collateral ligament, lateral collateral ligament, and the annular ligament holds the joint together to prevent dislocation. The joint complex has 2 joints namely, the proximal radioulnar joint for flexion & extension and the radiocapitellar joint for forearm pronation & supination.

Diagnosis:

• History of injury
• Physical examination
• A child is reluctant to move the injured arm because of pain
• The injured arm is kept on the side.
• The forearm is usually flexed and pronated
• Some tenderness at the radial head area

Imaging:

• X-ray to rule out possible fracture but are often unnecessary
• Ultrasonography and MRI performed to confirm ligament involvement

Treatment:

• A reduction is a gentle maneuver that allows the bone to go back into its normal place. If unsuccessful after 2-3 attempts, X-ray is needed to rule bone fracture. 
• Over-the-counter pain medicine, such as acetaminophen or ibuprofen may be given. Never give aspirin to a child under age 12.

Prognosis:

• It is usually excellent with treatment. If left untreated, the child may be permanently unable to fully move the elbow. 

Prevention:

• The most important thing is to know the risk 
• Avoid tugging or pulling a child's hand or wrist
• Never swing a child by holding the hand or wrist
• Never lift a child by holding the hand or wrist instead grasp under the arm
• Some children are more likely to get it again, a doctor may teach the family the reduction maneuver

Strain and Sprain

Aside from the other traumatic soft tissue injuries like contusions, sprain and strain are the two most common acute soft tissues injuries that involve muscles, tendons, and ligaments. These injuries often occur with our daily simple or complex activities like occupation, hobby, recreation, sports and exercise activities. These soft tissue injuries have two categories, the acute injuries and overuse injuries. Sprain and strain, together with contusions, belongs to the sudden traumatic acute injuries of the soft tissues. The overuse injuries, such as the tendinitis and bursitis, occur gradually over time and constantly injuring the soft tissue without allowing enough time to heal between occurrence.

            mild 2nd degree sprain, rotated inwards. (Photo credit: Wikipedia)
 

SPRAIN

A sprain is a sudden trauma involving one or more ligaments around a joint. The ligaments, similar to tendon and fascia which are connective tissues, are tough and fibrous connective tissues that connect one bone to another bone to maintain stability and resist mechanical stresses. Sprains can occur in any joint but are most common in the knee, ankle, wrist, and thumb. The injury can be minor that resolves in a few days or it can be a major injury requiring surgical intervention and a period of immobilization. Pain and rapid swelling follow after a sprain. In most cases, the severity of sprain depends on the pain and swelling. The greater it is, the more severe the injury is.

Causes

Risk factors that increase the occurrence of sprain include:

• Twisting, stretching or any excessive forces being applied to the joint that go beyond the functional range of motion 
• Fatigue of muscles predisposes to injury. A tired muscle doesn't give enough support to a joint
• A fall and landing on an outstretched arm, landing on the side of their foot, or twisting a knee with the foot planted firmly on the ground.
• Individuals with sedentary lifestyle, usually less or no physical activity
• Inadequate or no warm-up and cool-down regimen in an exercise or an activity  
• Bumping into a hard object or person such as contact sports
• Poor conditioning and poor techniques to an exercise or an activity

Signs and symptoms

• Pain around the affected joint
• Muscle pain and spasm
• Swelling follows soon after the injury
• Bruising may appear later sometimes at some distance from the affected joint (hematoma) or it may not appear at all
• Joint instability depends on the severity of the injury
• Sometimes may hear a popping sound or feel a tear 
• A loss of the ability to move and use of the affected extremity or to bear weight may lead to joint stiffness

Diagnosis

• Physical examination to demonstrate clinical presentation and method of injury
• X-ray for possible bone fracture
• Magnetic Resonance Imaging (MRI) performed for a detailed look at surrounding soft tissues and the ligament

Grading of injury

Grade I  

• Mild pain and swelling 
• Little to no instability, Little to no tear of the ligament 
• Stretched but intact with no loss of function

Grade II  

• Moderate pain and swelling, 
• Minimal instability of the joint 
• Partial tearing of the ligament from a third to almost all its fibers 
• Decrease in the ROM 

Grade III  

• Severe pain and swelling
• Significant instability of the joint
• Complete rupture of the ligament
• Significant decrease in ROM

                                                                        STRAIN                                                 

A strain is an injury involving the musculotendinous unit that involves a muscle, tendon or their attachment to bone.  Functionally, the tendons and muscles  tightly integrated to move bones.Tendons are fibrous cords of tissue with one end of the tendon connects to muscle and the other end of the tendon connects to a bone. The same with a sprain injury, any excessive forces that stretch or tear the muscle and/or tendons produce an injury. Muscle strains are particularly common in the legs and back, such as hamstring strains and lumbar (lower back) strains.

Causes

A strain caused by an excessive twisting or a pulling action to a muscle or tendon. This is common to contact sports and other sports that require extensive gripping and quick starts. 
The injury can be acute or chronic, just like in a sprain injury 

4 days after a pulled hamstring. Two images of the same leg. One of the pictures was shot through a mirror (Photo credit: Wikipedia)

Sign and Symptoms

• The severity is dependent on the extent of the injury.
• Pain and muscle spasm
• Localized swelling
• Loss of muscle function
• Limited joint range of motion

Grading of injury

Grade I  

• Localized pain, minimal swelling, and tender to touch

Grade II  

• Localized pain, moderate swelling, tenderness, and impaired motor function

Grade III  

• A palpable defect of the muscle, Severe pain, and poor motor function

Treatment of Sprain and Strain

In the acute phase, the focused is on the reduction of pain and swelling and further injury

• PRICE stands for protection, rest, ice, compression, and elevation 24 hours up to 72 hours to reduce pain and swelling or until swelling improves
• No heating such as hot baths or hot packs
• Refrain alcoholic beverages because it will increase bleeding and swelling, and slow down the healing process
• Massage may increase bleeding and swelling in the acute phase
• Don't avoid instead a reduction regular exercise or activities  
• Protection may include a non-weight bearing on the injured site using a crutch may help. A splint or brace may also be helpful for moderate injuries while a surgical repair required for severe injuries
• Apply an ice pack or a cold pack for 15 to 20 minutes to prevent frostbite, 6 to 8 times a day.
• Compression bandages to help reduces swelling
• Elevation of the injured extremity above heart level help also reduces swelling
• Prescription medication or over-the-counter pain relievers, such as ibuprofen (Advil, Motrin IB) and acetaminophen (Tylenol)  may be helpful to manage pain and inflammation during the healing process

Start the physical therapy programs early to prevent or minimize the effects of deconditioning. Depending on the patient's rate of recovery such as diminished pain and swelling, incorporate a series of exercises in the rehabilitation to help reduce swelling, prevent joint stiffness, and restore normal, pain-free range of motion. Exercises include: 

• Weight-bearing and balancing exercises
• Strengthening, endurance, and flexibility exercises to increase strength and regain flexibility
• Treatment modalities such as an Ultrasound, a soft-tissue massage or techniques, and a manual therapy techniques(Joint oscillation) help reduce pain and inflammation
• A  continuous passive motion (CPM) machine to maintain or promote flexibility of the joint.

As pain decreases and function improves, progression to functional training based on patient's occupation and/or recreational goals. Patient education and training/retraining for instrumental activities of daily living (IADL). A full recovery may allow a patient to return to full daily activities, including sports. Remind patient the potential danger in accelerating the rehabilitation program as it may lead to serious consequences.

Preventive measures

• Avoid exercising or doing sporting activities when you feel tired or in pain.
• Maintain a healthy, well-balanced diet to keep muscles strong and full of energy
• Wearing appropriate footwear designed for a specific activity such as sports shoes or a protective equipment. A high-heeled is more likely to sprain your ankle than if you wear flat shoes. 
• Practice safety measure to help prevent falls such as slippery floors, cluttered areas, and others
• Run on or walk on even surfaces may help
• A taping, strapping or wrapping your knees, ankles, wrists to protect joints. 
• Do regular stretching and strengthening exercises daily to maintain a healthy weight and promote general well-being
• Be in proper physical condition and in a high spirit to play a sport.
• A short warm-up and cool-down regimen that include stretching may help reduce injuries before engaging in any sports or exercise 

Lateral Epicondylitis (Tennis Elbow)

English: Lifting backpack (Photo credit: Wikipedia)

I. Overview

The most common overuse syndrome characterized by inflammation or degeneration at the common extensor tendon that joins the forearm muscles to the lateral epicondyle of the elbow. The forearm muscles and tendons become damaged from overuse leading to pain and tenderness on the outside of the elbow. It is a strain injury from playing tennis or other racquet sports. However, you can still get tennis elbow even if you are not a tennis player and is actually more common in non-tennis players. Any repetitive gripping activities or several other sports can also put you at risk. The structures primarily involved are the wrist extensors, particularly the extensor carpi radialis brevis. It also affect the extensor digitorum, extensor carpi radialis longus, and extensor carpi ulnaris.

II. Functional Anatomy

A synovial hinge joint formed between the distal end of the humerus in the upper arm and the proximal ends of the ulna and radius in the forearm. The elbow joint complex made up of four articulation,  the humeroulnar, humeroradial, superior radioulnar, and inferior radioulnar joints. Muscles, ligaments, and tendons hold the elbow joint together to provide functional movements and dynamic stabilization to perform skilled and precise motions. The coordination of multiple muscles allows two degrees of freedom of movements,  the combinations of flexion-extension and pronation-supination. The two epicondyles are actually the bony protuberance at the distal end of the humerus, the medial and lateral epicondyle. The forearm muscle tendons attach the muscle to bone. In lateral epicondylitis, the injury is on the tendon attachment on the lateral epicondyle of the humerus. The tendon usually involved is the Extensor Carpi Radialis Brevis (ECRB). Experiences pain and localized tenderness in the lateral side of the elbow.

Elbow - coude (Photo credit: Wikipedia)

III. Contributing factors

1. Overuse
Any repetitive wrist action against resistance during extension and supination may produce damage to the forearm muscle, particularly the extensor carpi radialis brevis muscle which stabilizes the wrist when the elbow is in extension. An example is ground stroke (backhand) in tennis.

2. Work and Activities 
There is a risk to any work or leisure activities that has no proper training, techniques, and equipment.

• Tennis/Racquetball/Squash - Check equipment for proper fit
• Fencing
• Weight Lifting
• Painters/Painting
• Carpenters/Bricklayers/Plumbers 
• Seamstresses/Tailors
• Cooks /Butchers
• Politicians (excessive handshaking)
• Musicians (pianists, drummers)
• Raking
• Knitting
• A lot of typing
• A lot of mouse work

3. Age
It is more common to individuals in their late 30's and 50's secondary to the normal loss of extensibility of connective tissue with age

4. Symptoms 
The symptoms of tennis elbow include pain and localized tenderness along the lateral aspect of the elbow especially over the lateral epicondyle that sometimes radiates into the dorsum of the hand although the damage is in the elbow. Pain usually increases with activity like picking up an object, holding a glass/cup, opening a door, or making shake hands. The elbow ROM is usually normal and involved only one side.

IV. Diagnosis

1. History Taking

• Information from patient
• Age of the patient (usual age group affected 30 to 50 years of age)
• How your current symptoms developed and medications
• Any occupational risk factors
• Recreational sports activities
• Family and Past medical history like an elbow injury before, history of rheumatoid arthritis or nerve disease

2. Physical Examination

• Inspections for swelling or ecchymosis.
• Palpation of the extremity for pain and tenderness at the lateral epicondyle
• The severity, the occurrence, and location of pain in relation to movement/activity
• Always examine ROM of the shoulder, elbow, and wrist on the affected side to evaluate for radiohumeral bursitis, osteochondritis of the capitellum, or PIN entrapment.

3. Tests

• Laboratory and imaging studies rarely needed
• X-ray or MRI (magnetic resonance imaging) to diagnose tennis elbow or rule out other problems like osteophytes, degenerative joint disease, or stress fracture
• Electromyography if there is radial nerve involvement
• Special orthopedic tests

Mills test

• The examiner palpates the patient’s lateral epicondyle with a thumb while passively pronating the forearm, flexing the wrist and extending the elbow.
• Positive test is reproduction of pain near the lateral epicondyle
• This test is also to use to indicate radial nerve involvement

Cozen’s test  

• Patient actively make a fist, pronate the forearm as well as radially deviate and extend the wrist against a counterforce that is being applied by the examiner.
• The positive test is the reproduction of pain near the lateral epicondyle.

Tennis elbow test

• The examiner resists the extension of the 3rd digit of the hand while stabilizing more proximal
• The positive test is the reproduction pain or discomfort in the region of the lateral epicondyle because it stress the extensor muscles and tendon

V. Differential Diagnoses

• Medial Epicondylitis
• Cervical Radiculopathy
• Plica Syndrome
• Elbow and Forearm Overuse Injuries
• Little League Elbow Syndrome
• Radial Nerve Entrapment 

Medical Intervention:
There are many treatment options for tennis elbow geared toward the goals of decreasing inflammation and analgesia. 

Nonsurgical Treatment
1. The patient is advice to avoid activities or work that aggravates the injury and treats pain and inflammation with protection, rest, ice, compression, and elevation.
2. Pharmacological intervention 

• Non-steroidal anti-inflammatory drugs (NSAIDs) for pain and inflammation such as ibuprofen, naproxen, or aspirin
• Monitor the effects on the gastrointestinal (GI) tract and renal function  with long-term use
• Topical NSAID such as diclofenac may offer some short-term relief.

3. Modalities

•  Ultrasound phonophoresis with hydrocortisone 
•  Electrical stimulation iontophoresis with NSAIDs and/or corticosteroid (dexamethasone) 

4. Counter-force bracing /Resting splints to relieve tension of the involved wrist extensor tendons
5. Physical therapy

•    Stretching to improve flexibility
•    Strengthening to increase functional activities
•    Progress from concentric to eccentric exercises and then resisted exercises as   tolerated
•   All exercise should be pain-free
•   Stretch and warm up before any sport or activity that will exercise your elbow or    arm.
•   Apply ice on your elbow after exercise

6. Steroid injections are very effective anti-inflammatory medicines to relieve symptoms.


Surgical Treatment
1. Recommended if the symptoms do not respond after 6 to 12 months of nonsurgical treatments
2. Surgical Option:
    a. Open surgery

• The most common approach to tennis elbow repair that involves making an incision over the elbow.

   b. Arthroscopic surgery

• This outpatient procedure involves using miniature instruments and small incisions. 

3. Rehabilitation

• Usually last 4 to 6 months postop
• Start the exercise with stretching and light, gradual strengthening exercise 2 months postop

4. Surgical risks

• Infection
• Nerve and blood vessel involvement
• Long-term rehabilitation process
• Loss of strength
• Loss of flexibility
• Possibility of another surgery

Home Care Program

• Give the same therapeutic program to the patient
• Patient education on modification of the activities that exacerbate the symptoms and use ice, elevation and rest as needed
• Advice patient about continued stretching and excercise to decrease the risk of recurrence
• Advice about the danger of rushing the recovery as it may worsen the damage

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Therapeutic Ultrasound

English: http://rheumatoidarthritis-symptoms.com - Rheumatoid Arthritis in the hands (Photo credit: Wikipedia)

Ultrasound in the medical community is used according to different purpose. It can be a diagnostic tool by imaging internal structures; the tumoricidal effects will help cancer patients in the destruction of tissue or as a valuable therapeutic agent in physical therapy. Ultrasound is one of the common deep heating therapeutic modality used by physical therapists today. Ultrasound consists of inaudible high‐frequency mechanical vibrations that produce thermal and nonthermal effects. The vibrations are created when an electrical energy is converted to acoustic energy through mechanical deformation of the piezoelectric crystal within the transducer/probe. The sound waves that pass through the skin causes a local deep heating and usually no sensation of heat will be felt by the patient. 




Therapeutic Effects

• Scar tissue breakdown by gentle massage of muscles, tendons and/ or ligaments in the treated area 
• Decrease joint stiffness
• Pain relief from the reduction of swelling and edema
• Increase local blood flow reduces local swelling and chronic inflammation
• Decrease muscle spasm

Nonthermal Effects

• Stimulation of tissue regeneration
• Increase macrophage responsiveness
• Pain relief from tissue relaxation
• Speed up soft tissue repair from increased blood flow
• Increase blood flow according to some studies promotes fracture healing
• Increase skin and cell membrane permeability enhance the cell repair effects of the inflammatory response, especially in soft tissue injuries

Indications                                                                                                                                         

• Ligament Sprains
• Muscle Strains
• Tendonitis
• Joint Inflammation
• Plantar fasciitis
• Metatarsalgia
• Facet Irritation
• Impingement syndrome
• Bursitis
• Rheumatoid arthritis
• Osteoarthritis
• Scar tissue adhesion
• Bone fracture
• Contracture
• Trigger point
• Dermal ulcer
• Plantar wart
• Pain

          

Contraindications

• Vascular abnormalities - thrombophlebitis
• Impaired pain or temperature sensory deficits
• Directly on the abdomen of pregnant women
• Directly over active epiphyseal regions (growth plates) in children
• Metal implants below the area being treated
• Local acute infection 
• Over the eyes, skull, testes, or cervical ganglia
• Over local malignancy
• Over the spine after laminectomy
• Over cemented prosthetic joint

Treatment Parameters

The treatment will be based on the diagnosis and the desired effects. Define the duration, frequency, duty cycle and intensity of treatment. 

Therapeutic ultrasound is in the frequency range of about 75 and 3 MHz. A frequency setting of 1 MHz is used for heating deeper tissues (up to 5 cm). A setting of 3MHz produces a higher temperature with a depth of penetration of less than 2 cm. 

The ultrasound can be administered using a pulsed or a continuous transmission mode. The pulsed mode is used in situations where a heating effect is not desirable, such as a fresh injury with acute inflammation because it minimizes the thermal effects (nonthermal effect). A continuous mode is effective in elevating the tissue temperature to produce the thermal effects on the tissues (due to the absorption of the sound waves). Nonthermal effects are from cavitations, micro-streaming, and acoustic streaming.

Ultrasound is applied using a transducer in three different techniques. One is in direct contact with the skin, the other way is to slightly hold one half-inch above a body part for water immersion technique, and lastly the indirect contact using a fluid-filled bag (bladder technique). The direct contact technique can be either the stationary or moving techniques. In the moving technique, the transducer should continuously move in a small circular manner or in a longitudinal stroke over the treated area. Each motion should cover half of the previous circle or stroke. The water immersion technique is recommended if the area to be treated is smaller than the diameter of the available transducers or if the body area is irregular with bony prominences. The body part is immersed in a plastic or rubber basin (no metal) filled with tap or degassed water. Move the transducer in a longitudinal stroke while keeping a 1/2' to 1' distance from the skin. The bladder technique is also ideal for bony prominent areas. This technique uses a thin plastic bag (surgical gloves or balloon) filled with water and is placed on the area to be treated. A coupling media are applied and slowly move the transducer on top of the bag.

The application requires a coupling medium (gels) applied on the area to be treated to reduce surface friction and assist transmission of the ultrasonic waves by preventing reflection of the waves away at the soft tissue air interface. Besides gels as a coupling media, mineral oil is can also be used. Different media have also different acoustic impedance that affects the transmission and absorption of the ultrasound. A two media having the same impedance will produce maximal transmission of energy or else a greater the difference in impedance, the greater the reflection that will occur, and therefore, the smaller the amount of energy that will be transferred.

The ultrasound intensity of continuous US is normally set between 0.5 to 2 W/cm2 of thermal effects while pulsing US normally set between 0.5 to 0.75 W/cm2 with a 20% duty cycle. Maximum energy absorption in the soft tissue occurs from 2 to 5 cm. Intensity decreases as the US waves penetrate deeper. They are absorbed primarily by connective tissue: ligaments, tendons, and fascia.

A typical ultrasound treatment will take from 3-5 minutes, depending on the size of the area being treated. Larger areas require duration of 5 minutes.

Duty cycles are the portion of treatment time that ultrasound is generated during the entire treatment or a Pulse ratio, which determines the proportion of time that the machine is ON compared with the OFF time. Some machines use ratios, and some percentage.

• In continuous US, the machine continuously generates ultrasound, giving 100% duty cycle and produces thermal effects.
• In pulsed US, a 50% duty cycle if the machine US generation (ON) have equal duration with machine in not generating US (OFF). This is a pulse ratio of 1:1.This is the nonthermal effects. 
• If the duty cycle is 20%, the US generated (ON) is 20% of the treatment, while the other percentage the machine is not generating US (OFF). This is the machine pulsed at a ratio of 1:4

Mode              Pulse Ratio                            Duty Cycle

Continuous                                                          100%

Pulsed                  1:1                                           50%

                             1:2                                           33%

                             1:3                                           25%

                             1:4                                           20%

                             1:9                                           10%

Phonophoresis

This is a non-invasive way of administering medications to tissues below the skin. This transdermal delivery of medication is recommended for patients who are uncomfortable with injections. Medications regularly used include anti-inflammatory agents or analgesics (cortisone). It is effective with both continuous and pulsed techniques.

Related articles

• Therapeutic Ultrasound
• The Role of Physical Therapy in Treating Chronic Pain
• Ultrasound for Wound Healing
• How ultrasound helps wound heal THREE TIMES faster
• Ultrasound Speeds Up Healing Times for Skin Ulcers Among Diabetics, Elderly
• Ultrasound can accelerate wound healing

Hot Moist Packs

These are the commercially available superficial heating modality used by many PT clinics and hospitals to provide moist heat. This consists of a silicate gel enclosed in a cotton canvas fabric. Silicate gel is the main property because it absorbs more water and when it is immersed in  hot water it provides a considerable store of heat energy that last 30 to 40 minutes. Heating is through conduction and has little to or no effect on the temperature of  deeper tissues. Hot packs are available in different size and shape to fit different body areas.

Physiologic Responses:

• Increases circulation - promotes soft-tissue healing
• Increases muscle temperature - decreases pain and stiffness
• Relaxes spasm 

Treatment Parameters:

• Hot packs are stored in a tank filled with hot water between 70 to 75 degrees Celcius.
• Application of the packs requires six to eight layers of towels around the hot pack to provide thermal insulation thus lessening the danger of burn
• Ideally, it should be applied on top of the patient. If the patient lies on top of the hot pack additional toweling is required
• Check skin after five minutes for excess or sign of a burn.
• Call the attention of the PT for discomfort
• Applied at least 20 to 30 minutes to achieve the desired effects

Method of Application:

One-towel method

• Fold four towels in half, width-wise.
• Place each towel on top of the other, forming eight layers of toweling.
• Place towels on the treatment area.
• Place pack on towels and cover pack with folded towel to retard heat loss.

Two-towel method

• Fold two towels lengthwise and
• Place one perpendicular over the other, forming a cross.
• Place pack in the center of the towels.
• Fold the ends of the towels over the pack, forming eight layers of toweling on top of the pack. Invert pack placing the eight layers of toweling on the patient.

Contraindications and Precautions:

• Impaired skin sensation
• Circulatory dysfunction - varicose veins, DVT, and arterial diseases
• Taking analgesic drugs
• Infections and open wounds - danger of cross-contamination
• Cancer and tuberculosis - may enhance the progression of the disease
• Gross edema
• Impaired cognitive - lack of comprehension
• Deep x-ray therapy
• Liniments
• Pregnancy - should not be applied directly over the uterus
• Fever
• Acute inflammation
• Presence of metal implants 
• Advanced age
• Menses - increases menstrual flow if applied to the lower back or over the pelvis

Advantages:

• Easy to apply
• Saves time for personnel
• Efficient in heat conduction
• Available in different sizes and shape to fit clinical needs
• Has more sedative effects than dry heat
• Low cost
• Long life
• Patient acceptance

Disadvantages:

• Not easily applied around shoulders and hips
• Somewhat heavy
• Cannot be used on extremely sensitive patients
• May cause skin rash

Alternatives:

Hot Compress 

• Ideal for home use; an alternative to hot moist pack
• Greater heat loss and need constant change.
• Place the towel in hot water and wrung out t properly if you use this method of application.

Hot Water Bottle

• A rubber hot water bottle applied in the same way as hot moist packs
• Ideal for home use

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Body Mass Index (BMI)

English: This is a person with a Body Mass Index of 19 (Photo credit: Wikipedia)

It is a recognized and generally accepted measure utilized by physicians and health experts to determine weight status (underweight, overweight, and obesity). It measures body fat based on height and weight. An elevated or higher BMI are increased risk for the following diseases:       

• Hypertension - high blood pressure
• Cardiovascular Disease - Stroke
• Coronary Heart Disease
• Gallbladder Disease
• Dyslipidemia/Hyperlipidemias - 
• Osteoarthritis
• Type 2 Diabetes Mellitus
• Some cancers - endometrial, breast, and colon cancer
• Sleep Apnea
• Epidural Lipomatosis

International Classification of Adult Underweight, Overweight, and Obesity according to BMI

Classification	BMI(kg/m2)
	Principal cut-off points	Additional cut-off points
Underweight	<18.50	<18.50
Severe thinness	<16.00	<16.00
Moderate thinness	16.00 - 16.99	16.00 - 16.99
Mild thinness	17.00 - 18.49	17.00 - 18.49
Normal range	18.50 - 24.99	18.50 - 22.99
		23.00 - 24.99
Overweight	≥25.00	≥25.00
Pre-obese	25.00 - 29.99	25.00 - 27.49
		27.50 - 29.99
Obese	≥30.00	≥30.00
Obese class I	30.00 - 34.99	30.00 - 32.49
		32.50 - 34.99
Obese class II	35.00 - 39.99	35.00 - 37.49
		37.50 - 39.99
Obese class III	≥40.00	≥40.00

Source: Adapted from WHO, 1995, WHO, 2000 and WHO 2004.

The BMI is calculated by the weight in kilograms divided by the square of the height in meters (kg/m²).

                                                       

Visit these links to determine your BMI:

BMI3D
Center for Disease Control and Prevention

(kg/m²)
(kg/m²
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