Physical Agents in Rehabilitation: Ultrasound and Phototherapy Jon DeBord, PT, MS, ATC, SCS Rehab Summit 2008 Infra-Red Phototherapy and Low Level Laser Jon DeBord, PT, MS, ATC, SCS Rehab Summit 2008 Red/Infra-Red Phototherapy 30 years of research Cell tissue response to certain frequency of low power light Used for about 20 years Visible red light (640nm) @ depth of 8-10 mm Wounds, cuts, scars, trigger and acupuncture points, specifically infections Infrared light (880nm) @ depth of 30-50 mm Bones, joints, and deep muscles Non- Coherent Light Source RevitaMed, Anodyne, others.
Phototherapy Benefits Release of nitric oxide from hemoglobin facilitates healing process Increased vascularity creates new capillaries Stimulate production of collagen Stimulate release of ATP energy to cells Increased lymphatic system activity edema evacuated by blood & lymph Phototherapy Benefits Decreased excitability of nervous tissue Stimulate fibroblastic activity repair process Increased phagocytosis important with infection fighting Induce thermal-like effect Stimulate tissue granulation & CT projections Stimulate acetylcholine release Phototherapy Side effects Research has shown no side effects Do caution patients taking photosensitive meds (tetracycline) Possibility of increased pain for short period treating chronic conditions Theory healing crisis or normal process of recovery
Clinic units Portable units Various pads Velcro straps Cost $900-$1400 Patients can purchase for maintenance RevitaMed Indications For treatment of: Myofascial pain, fibromyalgia, joint pain, bruising, fractures, muscle problems, edemas, wounds Antibacterial effect Induces production of collagen Increases tensile strength and elasticity in scar tissue Contraindications Pregnancy Active Cancer No research, just fear of using with these patients
Diabetic Peripheral Neuropathy Restoration of protective sensation Improve gait/balance Potential to improve ambulation and decrease falls Reduction in pain, pain meds Improved wound healing in chronic nonhealing wounds Red/Infra-Red Devices Protocols Varies with each patient Gait training Balance and Proprioception ROM and Flexibility Strengthening and Endurance Typically, 3x/wk x 4-8 weeks Claims.12-15 treatments for effects
Low Level Laser Therapy Low Level Laser Therapy Coherent Light Primary Effects Similar to effects of IR Therapy Secondary Effects Cell proliferation, protein synthesis, growth factor secretion, neurotransmitter modification Tertiary Effects System effects Increase immune response, stimulate bone healing Conditions Commonly Treated with Low Level Laser Carpal Tunnel Syndrome Soft Tissue Injuries Arthritis Tendonitis Edema Nerve Injury Sprains/Strains Wounds Burns
Low Level Laser Therapy Contraindications Absolute Pregnancy Malignancy Avoid the Thyroid Gland Avoid the Epiphysis Photosensitive patients Immune-suppressed patients Relative Botox Injections Anti-Inflammatory meds Steroid Injection Other considerations Some machines use magnetic energy as well no pacemakers Low Level Laser Therapy Indication Open Wound Wound Periphery Superficial Pain Deep Lying Pain Dose in J/cm 2.001 to.02 J/cm 2 0.5 to 1.0 J/cm 2 1 to 2 J/cm 2 2 to 5 J/cm 2 Low Level Laser Therapy Diagnosis Pain, neuralgia General Stimulation Edema, swelling Inflammation Infection Frequency Range 1-1000 Hz 700 Hz 1000 Hz 5000 Hz 10,000 Hz
Low Level Laser Therapy TerraQuant Protocols Program One Two Three Four Five Treatment Pain Syndrome Chronic Pain Syndrome Skin and Wound Care Anti-Aging and Cosmetic Manual Pulse Frequency 50 Hz 5 Hz 1000 Hz 1000 to 3000 Hz 5 to 1000 Hz Time 5 min 5 min 4 min 4 min Variable Low Level Laser Therapy Low Level Laser Therapy General Considerations To Move or Not to Move Movement ok but may increase time necessary to provide the dosage MATH Contact Contact, even overpressure encouraged to gain maximum absorption of light Not indicated for wound application Refraction May be necessary to treat same tissue at multiple angles to achieve desired affects Frequency Acute daily for 2-3 days Early 3x/week for 2 weeks Later 1x/week for 4 weeks
Advantages of Each Infra-Red/Red Lasers have limited wavelength capability and beam width Size of the wounds/areas to be treated are vastly different Low Level Laser Deeper penetration of light Focused treatment area More research available (2500+) Shorter treatment times Ultrasound Evidence-Based Practice
Literature Review Gürsel et al (Phys Ther 2004) US+Exercise vs. Sham US+Exercise for softtissue disorder of shoulder 40 subjects (mean onset 8.7 months) US at 1MHz 1.5W/cm 2 10 minutes IFC Exercise 5x/week for 3 weeks No statistically significant difference between groups Literature Review Young and Dyson (Ultrasound in Med and Biol 1990) US(0.5W/cm 2 ) causes macrophages to release factors stimulating fibroblast proliferation Mummery (1978) US increased fibroblast mobility Harvey et al (Rheum Rehab 1975) 20% increase in collagen secretion with continuous US at 0.5W/cm 2 30% increase with pulsed US at 0.5W/cm 2 Literature Review Callam et al (Lancet 1987) Chronic Leg Ulcers 1Mhz, 0.5W/cm2, pulsed Performed weekly US vs. control 20% increase in healing rate with US Lundeberg et al (Scan J of Rehabil Med 1990) Similar design to Callam et al (1987) No statistically significant difference Trend suggested US more effective than placebo Sample (n=44) Authors stated that improvement of less than 30% could not be detected
Literature Review Webster (1980) Skin wounds US at 0.1 W/cm2, 3x/week for 2 weeks Immediately after injury Elasticity and tensile strength of scar much greater than control Literature Review Dyson (1981) US during Inflammatory Stage Skin Wounds Increased collagen deposition in wound Collagen fibers more closely resemble normal tissue Enwemeka et al (Ultrasound in Med and Biol 1990) US during Inflammatory Stage Tendon Inj. US at 0.5W/cm 2 Increased tensile strength and elasticity Literature Review Pilla et al (J Orthop Trauma 1990) Low intensity US on rabbit legs 1.5 or 3.0 MHz pulsed at 0.3W/cm 2 Maximum bone strength at 17 days with US and 28 days in controls Tsai et al (Chinese J of Physiology 1992) Femoral Fractures Increased healing rate with 1.5MHz at 0.5W/cm 2 Inhibited healing with 1.5MHz at 1.5W/cm 2
Literature Review Dyson and Brookes (1983) Fibula Fractures 1.5Mhz at 0.5W/cm 2 vs 3.0MHz at 0.5W/cm 2 Done either first 2 weeks or weeks 3-4 Treatments 5 minutes 4 times per week Most effective during first 2 weeks of repair Literature Review Ebenbichler et al (N Engl J Med 1999) US vs. Sham US for Calcific Tendinitis of the shoulder 63 subjects (70 shoulders) randomized by shoulder US at 0.89MHz, 2.5W/cm 2, pulsed 1:4, 15 minutes 5x/week times 3 weeks, 3x/week times 3 weeks (24 total) Results 6 weeks US Group Resolved in 19% <50% in 28% Sham Group None resolved <50% in 10% 9 months US Group Resolved in 42% <50% in 23% Sham Group Resolved in 8% <50% in 12% Literature Review Ebenbichler et al (BMJ 1998) US for mild to mod carpal tunnel syndrome 45 subjects with bilateral CTS Sham US vs. US at 1Mhz, 1.0W/cm2, pulsed 1:4, 15 minutes 5x/week x2weeks, 2x/week x5weeks (20 total) Results Pain Significantly improved in US Rx group No change in sham US Electroneurography Significantly improved in US Rx group Function Strength significantly improved in US Rx group
Literature Review - Coupling Media Klaiman (Med & Sci in Sports & Exer 1998) Phonophoresis (gel with.05% fluocinonide) vs. standard gel US continuous 1MHz at 1.5W/cm 2 x8 min, 3x/wk x3 wks Results US decreased pain, increased pressure tolerance Addition of medication of no further benefit Casarotto et al (Arch Phys Med and Rehabil 2004) Gel vs. Mineral Oil vs. White Petrolatum vs. Degassed Water Results Thinner layer best Gel and Degassed water better Literature Review Hayes, et al (J Athl Train 2004) Three MHz Ultrasound Heats Deeper Into the Tissues Than Originally Theorized Measured muscle temp of 1MHz vs 3MHz vs sham US at 2.5cm depth (1.5W/cm 2 ) Results Vigorous Heating at 3.4 Minutes 40 C at 4 minutes No change in sham or 1MHz Only study showing penetration to this depth Most report effective depth of 0.8-1.6cm Literature Review Morrisette et al (JOSPT Dec 2004) Temperature Change in Lumbar Periarticular Tissue with Continuous Ultrasound US at 1.5W/cm 2 vs. US at 2.5W/cm 2 Same for 1 st 3 minutes 1.5W/cm 2 reached 38.1 C in 10 min 2.5W/cm 2 reached 39.3 C in 10 min None of the subjects reported discomfort
Indications Soft-tissue shortening Increased collagen fiber elasticity Inflammation Activation of macrophages Tissue healing Secretion of collagen Organization of Collagen Must have sufficient arterial circulation Do not sonate over Eyes Gravid Uterus Spinal Cord (after laminectomy) Carotid Sinus Cervical Ganglia Cancer Epiphyseal Plates Contraindications Specific Interventions Choosing Intensity Thermal Effects Higher Intesity Non-Thermal Effects Lower Intensity Choosing Intensity Acute Conditions <0.5 W/cm 2 Chronic Conditions Higher Intensity as appropriate
Specific Interventions Pulsed Non-Thermal Effects Soft Tissue Repair Stimulation of Blood Flow Bone Fracture Repair Tendon Repair Continuous Thermal Effects Muscle Spasm Joint Stiffness Pain Specific Interventions Joint Contracture / Scar Tissue Elevation of tissue to 40 C Continuous 1.0-2.5W/cm 2 Frequency based on tissue depth 5 min per field (10cm 2 for 5cm 2 sound head) 3x/week for 3-4 weeks Follow with stretching of heated tissue Specific Interventions Pain and Muscle Spasm Increased pain threshold due to decreased nerve transmission Continuous 0.5-1.0W/cm 2 Frequency based on tissue depth 5 min per field (10cm 2 for 5cm 2 sound head) Daily for up to two weeks
Specific Interventions Bursitis and Tendinitis Increased fibroblast activation and collagen secretion Pulsed (20%) 0.5-1.0W/cm 2 Frequency based on tissue depth 5 min per field (10cm 2 for 5cm 2 sound head) Daily for up to two weeks Specific Interventions Calcium Deposits Facilitate re-absorption of deposits in soft tissue Pulsed 1:4 0.89MHz 2.5W/cm 2 15 minutes 5x/week times 3 weeks, 3x/week times 3 weeks (24 total) Specific Interventions Tissue Healing Accelerate transition Inflammatory to Proliferative to Remodeling stages of healing Pulsed 1MHz 0.5W/cm 2 5 min per field (10cm 2 for 5cm 2 sound head) 3x/week