Monday, April 29, 2013

DEVICE BASICS



















Basic Device Start Up:
Set the “Stimulator Output Control” knob and the “Ultrasound Output Control” knob fully counter-clockwise
1.      Turn on by pressing the "Power Switch".
2.      Set “Output Display Selector” rocker switch to the “Ultrasound “position.
3.      Set the "Treatment Time" selector to the number of minutes for treatment (5 to 8 minutes is recommended).
4.      Set "Power/Intensity Selector” rocker switch to the "Intensity" setting.    
5.      Set "Pulsed/Continuous Selector" rocker switch to “Pulsed” (acute) or “Continuous” (chronic).
6.      Set the "Stimulator Polarity Selector" rocker switch to “Negative” and apply distal ground electrode.
7.      Depress the "Timer On/Off Selector" button to “On” to activate the unit. Apply approximately 1 heaping tablespoons of coupling gel to the face of the Soundhead.
8.      Rotate the "Ultrasound Output Control" knob clockwise until the desired intensity is indicated in the "Output Display" (0.50 W/cm2 is recommended).
9.      Switch the “Output Display Selector” rocker switch to the “Stimulator” setting to observe the applied voltage.

Apply the Soundhead to the patient and keep it moving then rotate the "Stimulator Output Control" knob clockwise until the patient reports a slight sensation. This will occur somewhere between 25 & 125 Volts as indicated on the “Output Display”. If no sensation is felt by the time 150 Volts is indicated, then discontinue treatment and troubleshoot the setup.  

This device requires a complete circuit so means an active electrode (Red or Soundhead) and a ground (Black or Large dispersive). These can be held in place with the supplied Velcro wraps.

Basic Steps
1.     Clean the skin of any dirt, sweat or applied oils.
2.     Place Ground - Place either Black Electrode or Large dispersive to act as the ground.
·        Black Electrode (active ground - treats local area using opposite polarity) 
·        Large dispersive (inactive ground – minimizes treatment effect of ground; must be at least 5x larger than active at a minimum greater than 25cm2) which is placed on either the torso, limbs or feet.
Distal ground – setting the ground to get the electrical field through the body by using either a lateral (elbow to elbow) or use a contralateral (example elbow to opposite side knee) electrode placement.
Lateral placement - ground the same area on the opposite side, “Use the left side to ground the right and the right side to ground the left” such as elbow to elbow.
Contralateral placement - "Use the lower body to ground the upper and the upper to ground the lower" and “Use the left side to ground the right and the right side to ground the left” such as left elbow to right knee or right wrist to left ankle.
Limb to Limb correspondence – Outside of arm to outside of leg, inside of arm of inside of leg, front of arm to front of leg, back of arm to back of leg.
Body to Limb correspondence - front of body to front of limb: back of body to back of limb and sides of the body to outside of the limb.
Ground Across– the active Red electrode or Soundhead is used right across from the ground: across either sides of knee or across torso from back to front or side to side.
Active Electrode – use either the Red Electrode or Soundhead on the area to be treated, for Soundhead use adequate amounts of ultrasound/conductivity gel and make sure it is a brand that can effectively transmit ultrasound
  • Red electrode – used on area to be treated as passive therapy or used in conjunction with Soundhead. 
  • Soundhead - the Soundhead provides ultrasound, pulsed voltage, and photon therapy.
    When used with the Soundhead place Red Electrode on the treated limb,.
When Using the Soundhead
  • During a treatment, keep the Soundhead perpendicular and firmly coupled. 
  • Move it in a circular manner at about three inches per second. Work an area about 4 times bigger than the Soundhead. 
  • Add more coupling gel as required to maintain full contact between the Soundhead and the patient.

Sunday, April 28, 2013

DIAGNOSIS OF TRIGGER POINTS AND MYOFACIAL PAIN SYNDROMES

Pain is a common complaint that is often refractory in its response to treatment. The successful treatment of pain in these conditions often involves identification of trigger points and referred pain patterns.
The clinical application of high voltage microsecond pulses provides an important diagnostic ability, along with its therapeutic benefit. The pulsed voltage can elicit mild pain when applied over trigger points. The patient will complain of no discomfort in the surrounding area, yet feel will slight pain over active trigger points. This is due to localized inflammation that changes the local cell membrane voltage, making the cells more responsive and reactive.
This diagnostic and therapeutic, ability is referred to by Bonica, M.D., in his seminal JAMA article "Management of Myofascial Pain Syndromes in General Practice".
Dr. Bonica says:
 "Trigger areas likewise may be quickly located with ultrasound/electrical stimulation which can also be used for treatment"

Dr. Bonica further writes:
“many cases which in the past have been diagnosed as subacromial bursitis, tendinitis, arthritis, periarthritis, and brachial neuritis were actually myofascial pain syndromes, with trigger areas in the muscles of the back and shoulder girdle and pain referred to the shoulder and arm."  (Example: Thoracic Outlet Syndrome)

Dr. Bonica adds:
"A very significant consideration, which makes this group of disorders particularly important to the general practitioner, is that they are relatively simple to manage, since most of the therapeutic procedures can be carried out in the physician's office, and, when treatment is properly executed, prompt cure ensues. On the other hand, if therapy is incorrect, chronic disability results."
 
Painful areas are often symptomatic of the underlying structural imbalance, injury or inflammation. This ability to identify myofascial pain syndrome, saves time and helps to uncover the underlying problem that has manifested as a pattern of chronic pain.


 Note: to identify reactive areas and points use negative polarity with voltage set at 80% of sensory level without lotion or ultrasound.


HEALING PROTOCOLS - Basic concepts


Ultrasound (US) - Ultrasound therapy consists of continuous or pulsed applications.
High intensity continuous - heats tissue (1-1.5 w/cm2) to initiate tissue repair and in chronic (1-.5 w/cm2) for tendon extensibility, initiates repair and lymph.
Low intensity continuous - (.1 w/cm2) stimulates tissue repair and bone growth.
High intensity pulsed - (1-1.5 w/cm2) stimulates blood flow and initiates healing
Low intensity pulsed - (.5-.1 w/cm2) stimulates tissue repair and bone growth.

 Electrical stimulation (ES) – offers the choice of positive or negative polarity.
1.     Positive is used in the first 6 hours post injury and also in ischemic wounds. This will control bleeding, build tissue, depolarize and sedate.
2.      Negative is then used up to 4 days post injury or in infection, it will hyperpolarize, stimulate repair, soften tissue and enhance blood flow.
3.     Positive alternating with negative is used from 4 days to 3 weeks post injury, positive for tissue repair while negative increases blood flow and nerve growth.


Positive Polarity

Negative Polarity



Hyperpolarize membrane
Membrane effect
Depolarize membrane



Oxidative reaction
Biochemical effects
Reductive reaction



Macrophages migrate
Galvanotaxis
Neutrophils migrate
Fibroblasts migrate
Chondrocytes migrate
Endothelial cells migrate
Epithelial cells migrate
Osteoclasts migrate
Osteoblasts migrate

Neurites grow faster



Maturation - epithelialization
Phase of Injury
Inflammatory
Remodeling
Early maturation
Ischemia

Infection













Acute vs. Chronic
Acute – use positive polarity, voltage 30-50 volts or (50-70) % of sensory and ultrasound either .5 w/cmpulsed or .1 w/cm2 continuous.
Chronic - negative polarity, voltage 50 - 100 volts or (80-90) % of sensory stimulation: ultrasound either 1 w/cm2 or .5 w/cm2 can be continuous or pulsed.

 
Ultrasound
The Soundhead – must be kept flat against the skin and constantly moving. Use nice even strokes toward the heart or slow circular motions. You should treat, for an adequate time to achieve the desired result, an area up to 25 cm2 and then move to new treatment area of up to 25 cm2.  So work small circular or rectangular sections then move on to a new area. 

Pulsed Voltage - The voltage should be set to 80% of sensory level; slowly increase the voltage until they feel it and then reduce the voltage by 20%. For the following the polarity should be kept on negative.
Thermal – US continuous at (1-1.5) watts/cm2 raises tissue temperature to 40-45 degrees C in 4 to 10 minutes.

·       Increase range of motion, extensibility of connective tissue and circulation to area
·       Initiate a healing response by targeted thermal to stimulate repair
·       Up-regulate heat shock protein (Hsp70) with salicylic acid as a topical agent to increase the removal of damaged or aged proteins (see Facial)
·       Muscle spasm

Minimal thermal – US pulsed at (.5 – 2) watts/cm2, this is a minimal thermal effect with a strong mechanical effect or continuous at (.2-.5) watts/cm2
·       Reduce calcium deposits (1) w/cm2 pulsed
·       Arthritis, encapsulitis and fibrositis (.75) watts/cm2 pulsed
·       TMJ, bursitis and tendonitis (.25) watts/cm2 continuous then pulsed
Non-thermal – US (.1 - .5) watts/cm2 pulsed or (.1) watts/cm2 continuous for a non-thermal effect that stimulates protein synthesis and tissue regeneration.
·       Reduce scar tissue (.5) watts/cm2 continuous then pulsed
·       Tissue regeneration  (.1) watts/cm2 continuous

Treatment times using ultrasound
·       4-8 minutes continuous
·       5-15 minutes pulsed