Physical Agents

Copyright 2013, 2009, 2003 by Saunders, an imprint of Elsevier Inc.
Introduction
This quick-reference manual is based on information presented in Physical Agents in Rehabilitation: From Research to Practice, 3e by Michelle H. Cameron. The information in this handbook is intended for use by qualified clinicians with prior training in the use of physical agents in rehabilitation and for students practicing under qualified supervision. The outline format of the handbook is meant to make the information easily accessible to rehabilitation professionals during clinical practice. For more detailed information and complete references please refer to Physical Agents in Rehabilitation: From Research to Practice, 3e.
Electrical Stimulation, Ultrasound, and Laser Light Handbook

Michelle H. Cameron, MD, PT, OCS Jennifer A. Rohl, BS
Notice: Knowledge and best practice in this field are constantly changing. As new research and experience broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of the practitioner, relying on his or her own experience and knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all the appropriate safety precautions. To the fullest extent of the law, neither the Publisher or Authors assumes any liability for any injury and/or damage to persons or property arising out or related to any use of the material contained in this book.
How to use this handbook

For ultrasound treatment 1. Read Chapter 7 on ultrasound in Physical Agents in Rehabilitation: From Research to Practice, 3e to review how this modality works and what the adjustable treatment parameters are. 2. Select appropriate treatment parameters for increasing tissue temperature or promoting tissue healing from the ultrasound parameters section in this handbook. 3. Determine ultrasound treatment location by referring to the ultrasound section in this handbook concerning your patient's problem. 4. These are treatment suggestions only. Adjust parameters based on clinical judgment.
For electrical stimulation treatment 1. Read Chapter 8 on electrical stimulation in Physical Agents in Rehabilitation: From Research to Practice, 3e to review how this modality works and what the adjustable treatment parameters are. 2. Select appropriate stimulation parameters for pain management, muscle contraction, edema control or promoting tissue healing from the appropriate electrical stimulation parameters section in this handbook. 3. Determine electrode placement by referring to the electrode placement section in this handbook concerning your patient's problem. 4. These are treatment suggestions only. Adjust parameters based on clinical judgment. For laser light treatment 1. Read Chapter 12 on laser light in Physical Agents in Rehabilitation: From Research to Practice, 3e to review how this modality works and what the adjustable treatment parameters are. 2. Select appropriate parameters for pain management or promoting tissue healing from the appropriate laser light parameters section in this handbook. 3. Determine laser light treatment location by referring to the laser light section in this handbook concerning your patient's problem. 4. These are treatment suggestions only. Adjust parameters based on clinical judgment.
Ultrasound
What is ultrasound? Ultrasound is a type of sound. It is similar to audible sound, except that it has a higher frequency. Ultrasound has a frequency of greater than 20 kHz (20,000 cycles/second). The human ear can hear sounds with a frequency of up to 20 kHz. Therapeutic ultrasound generally has a frequency of between 1 and 3 MHz (millions of cycles/second) in order to achieve a depth of penetration through soft tissue of between 1 and 5 cm (with 1 MHz penetrating deeper than 3 MHz). How therapeutic ultrasound works When ultrasound passes through tissue some of it is absorbed by the tissue producing molecular motion. This motion causes friction between particles and thus, with sufficient ultrasound intensity, an increase in tissue temperature. The tissue heating produced by ultrasound can increase local blood flow and collagen extensibility, reduce pain and muscle spasm, increase local circulation and enzyme activity and produce a mild inflammatory response. It has also been found that ultrasound has a range of effects that are not related to its ability to increase tissue temperature. These effects are known as nonthermal or mechanical effects and include stable cavitation, microstreaming and acoustic streaming. Research indicates that these nonthermal effects may promote soft and bony tissue repair and increase cell and tissue membrane permeability.
Ultrasound parameters Intensity: The amount of power per unit area, generally measured in W/cm2. This measure of dosage should be used when selecting ultrasound treatment parameters.
1 MHz
3.3 MHz
Effective Radiating Area (ERA): The area of the crystal where the intensity of the ultrasound is 5% or greater than the measured maximum.
Power: The amount of acoustic energy per unit time, generally measured in Watts. This measure of dosage is only used during calibration of the ultrasound machine. It should not be used when selecting ultrasound treatment parameters. Frequency: Number of cycles per unit time. Ultrasound frequency is usually measured in Megahertz, (MHz, millions of cycles/second). Increasing the frequency decreases the depth of penetration.
(These drawings are not actual size, but are drawn to scale. Light beige represents E.R.A. while darker beige represents actual crystal surface area.)
Beam Nonuniformity Ratio (BNR): The ratio of the highest intensity in the field to the spatial average intensity.
Peak Average
Duty cycle: The proportion of the total treatment time during which ultrasound is being delivered. The duty cycle may be expressed as a percentage or the ratio of the on time to the total cycle time. e.g. 1:1 = 100% = continuous 1:2 = 50% = 5ms on: 5ms off 1:5 = 20% = 2ms on: 8ms off
100%
E.R.A diamter
Pulsed: Ultrasound can be delivered either continuously or in a pulsed mode. Pulsed ultrasound is on some of the time and off some of the time.
100% 5 ms
50%
5 ms 20%
5 ms
2ms 50%
8 ms
2ms
5 ms
5 ms 20%
5 ms
2ms
8 ms
2ms
Clinical application of ultrasound

Transmission medium When applying therapeutic ultrasound to a patient, a transmission medium must be placed between the patient's skin and the ultrasound transducer. This transmission medium ensures effective ultrasound transmission to the patient. Good ultrasound transmission media include manufactured ultrasound gel, ultrasound lotion and water. Other topical preparations, such as creams or ointments, not intended for ultrasound transmission should not be used since many of these transmit ultrasound poorly. Since air is a poor transmitter of ultrasound the amount of transmission medium applied must be sufficient to eliminate any air between the transducer and the patient's skin.
Contact Complete contact should be maintained between the entire transducer surface and the patient's skin throughout treatment. Area of treatment Ultrasound should generally be used to treat areas equal to twice the ERA of the transducer. Treatment recommendations are based on treating areas of this size. If treatment of a larger area is required the treatment time should be increased proportionately.
E. R. A. = 2x E. R. A.
Ultrasound gel or lotion
Motion of transducer The transducer should be moved throughout the treatment. It may be moved in a circular or stroking manner.
The speed of transducer movement should be sufficient to maintain constant motion while avoiding increasing the treatment area or losing consistent and constant contact with the skin.
Contraindications for the application of therapeutic ultrasound 1. Over malignant tissues or space occupying lesions 2. Over a pregnant or possibly pregnant uterus. 3. Over the stellate ganglion, the spinal cord after laminectomy, subcutaneous major nerves and the cranium 4. Over a cemented prosthesis or in areas where plastic components are used 5. Over a cardiac pacemaker or its lead wires 6. Over or adjacent to vessels containing arterial or venous thrombi or with thrombophlebitis 7. To the eyes 8. Over the male or female reproductive organs. Precautions for the application of therapeutic ultrasound 1. Areas of acute inflammation 2. Over unclosed epiphyseal plates in skeletally immature individuals 3. Only low-dose ultrasound, such as that used in fracture healing, should be applied over the area of a fracture. 4. Over breast implants 5. The ultrasound applicator should be moved throughout the treatment. 6. Areas of reduced sensation or circulation. NOTE: It has been shown that ultrasound does not adversely effect the mechanical properties of silastic (the plastic commonly used in finger joint arthroplasty) or the fixation of metal pins, screws or plates.
Recommended ultrasound treatment parameters Increase tissue temperature Duty cycle Continuous Tissue depth 2 10 cm Frequency 1 MHz Duration (2 x ERA) 5 10 min Intensity 1.5 2.0 W/cm2 Nonthermal effects Duty cycle 20% Tissue depth 2 10 cm Frequency 1 MHz Duration (2 x ERA) 5 10 min Intensity 0.5 1.0 W/cm2
Continuous < 2 cm 3 MHz 5 10 min 0.5 W/cm2
20% < 2 cm 3 MHz 5 10 min 0.5 1.0 W/cm2
10
11
Recommended ultrasound treatment sites and parameters Knee contracture
Finger contracture
Duty cycle Frequency
Continuous 1 MHz
Duty cycle Frequency Duration (2 x ERA) Intensity
Continuous 3 MHz 5 10 min 0.5 W/cm2
Duration (2 x ERA) 5 10 min Intensity 1.5 2.0 W/cm2
12
13
Low back pain: Increase circulation
Lateral collateral ligament (LCL) sprain
Continuous 1 MHz
Duty cycle Frequency Duration (2 x ERA) Intensity
20% 3 MHz 5 10 min 0.5 1.0 W/cm2
14
15
Sacral pressure ulcer
Electrical stimulation
What is electrical stimulation? Electrical stimulation is the application of an electrical current to the body via transcutaneous electrodes for therapeutic benefit. How electrical stimulation works Electrical stimulation works primarily by stimulating peripheral nerves to produce action potentials which are transmitted along these nerves. Sensory nerves transmit action potentials from the periphery towards the central nervous system to produce a sensation frequently described as tingling. Motor nerves transmit action potentials towards the periphery to cause contraction of the muscles they innervate. When nociceptive (pain transmitting) nerves transmit action potentials towards the central nervous system the individual feels pain. The different types of nerves, sensory, motor and nociceptive, have different minimum thresholds for responding to electrical stimulation. These thresholds depend on the duration and amplitude of the applied pulse of electrical current. Sensory nerves respond to shorter and lower amplitude pulses than motor nerves and motor nerves respond to shorter and lower amplitude pulses than pain transmitting nerves. The minimum threshold for stimulation of these types of nerves is most readily demonstrated by the amplitude duration curves on the following page.
20% 3 MHz
16
17
Electrical stimulation devices are designed to produce pulsed currents where the pulse amplitude and duration can be selected to optimally stimulate sensory nerves only (using short pulses of 25 to 40 s (microsecond) phase duration or 50 to 80 s pulse duration) or sensory and motor nerves (using longer pulses of 75 to 175 s phase duration or 150 to 350 s pulse duration) while, in both cases, not stimulating nociceptive fibers (which would require longer pulse durations or pulse amplitudes).
Electrical stimulation parameters

Waveform The waveform may be one of three general typesdirect current, alternating current or pulsed current. Direct current (DC) : A continuous unidirectional flow of charged particles. DC is used for iontophoresis, for stimulating contraction of denervated muscle, and also occasionally to facilitate wound healing.
+ polarity
200
Current strength (mA)
180 160
A Sensory Motor A Sharp pain
C Dull pain Denervated Muscle
Current amplitude
Time - polarity
20 0 10 40 100 300 600 Microseconds ( sec) 1.0 10 Milliseconds (msec) 100
Alternating current (AC) : A continuous bidirectional flow of charged particles. AC is generally used for interferential, premodulated, and Russion protocol stimulation.
+ polarity
Pulse duration (pulse width)
Current amplitude
Time - polarity
18
19
Interferential current: The waveform produced by the interference of two medium frequency (1,000 to 10,000 Hx) sinusoidal ACs of slightly different frequencies. These two currents interfere to produce a beat current with a frequency equal to the difference between the two applied currents and an amplitude equal to the sum of the amplitudes of the two applied currents. This form of stimulation is thought to be more comfortable than other types of current because the current which passes through the skin has a low amplitude. Interferential stimulation is most commonly used for pain management and in such applications is a form of TENS.
Premodulated current: An alternating current with a medium frequency and sequentially increasing and decreasing current amplitude produced with a single circuit and only two electrodes. The beat frequency of this current, to which the body responds, is equal to the frequency of the variation in pulse amplitude.
+4 Amplitude
1 0 -4 100 Hz
5,100 Hz
Russian protocol: A form of stimulation designed to stimulate motor nerves to optimize muscle strengthening. It is comprised of fifty 10 ms bursts per second with a 2500 Hz alternating current within each burst.
+ polarity Current amplitude 10 msec 10 msec 10 msec 0 Carrier frequency 2,500 Hz
100 Hz
5,000 Hz
Time - polarity
20
21
Pulsed current: A flow of current that stops and starts, being made up of pulses. Pulsed current may be monophasic (unidirectional) or biphasic (bidirectional).
Current amplitude + polarity + polarity
Pulsed currents have a number of adjustable features including: phase duration, pulse duration, pulse amplitude and pulse frequency. Phase duration: The duration of one phase of a pulse. Phase duration is generally expressed in microseconds (s = 10-6 seconds) or miliseconds (ms = 10-3 seconds).
0 Time
0 Time - polarity - polarity
Pulse duration: Pulse duration is generally expressed in microseconds (s = 10-6 seconds). Amplitude (intensity): The magnitude of current or voltage. Pulse frequency (rate): Number of pulses per second. Pulse frequency is expressed in pulses per second (pps) or cycles per second (hertz, or Hz).
The most common monophasic pulsed current has the waveform shown below and is known as high volt current because of its high peak voltage (and current).
Current amplitude + polarity
0 Time - polarity
Biphasic pulses may be symmetrical (and balanced), asymmetrical and balanced, or asymmetrical and unbalanced. Most pulsed currents used are balanced. Some are symmetrical and some are asymmetrical.
Current amplitude + polarity 0 Time - polarity - polarity 0 + polarity x x=y y Time - polarity 0 + polarity x y Time x=y
Modulation: Any pattern of variation in one or more of the stimulation parameters. Modulation is used to limit neural adaptation to an electrical current. Modulation may be cyclic or random.
22
23
When using interferential current, modulating the current amplitude moves the area of maximal stimulation within the treatment area. On most devices this is called vector or scan.
Electrode selection Most electrodes used clinically at this time are self-adhesive. Self-adhesive electrodes can be applied directly to the patient's skin. This type of electrode can be reused as long as it maintains its adhesive property. The length of time this type of electrode maintains its adhesive property varies with manufacture. Keep these electrodes in a sealed plastic bag between uses and slightly moisten the adhesive surface prior to use in order to maximize longevity.
General guidelines for electrode placement Specific guidelines for electrode placement for specific applications are given in the sections on these applications. Place electrodes at least 2 (5 cm) apart. The further apart the electrodes the deeper the current flow. The closer together the electrodes the more superficial the current flow.
Skin Electrodes closer together Electrodes farther apart
Current
24
25
For motor stimulation, one electrode should be placed on the motor point for the muscle (generally in the middle of the muscle belly) and the other electrode should be placed elsewhere on the muscle so that the current flows parallel to the muscle fibers.
Motor point biceps brachii
Contraindications for the use of electrical stimulation 1. Demand cardiac pacemaker or any implanted electronic device 2. Placement of electrodes over carotid sinus (anterior neck) 3. Areas of venous or arterial thrombosis or thrombophlebitis 4. Pregnancy over or around the abdomen or low back 5. Directly over the eyes. Precautions for the use of electrical stimulation 1. Cardiac disease 2. In patients with impaired mentation or in areas with impaired sensation 3. Malignant tumor 4. Areas of skin irritation or open wounds. 5. After the application of any physical agent, such as heat, ice, or ultrasound, which may alter skin permeability 6. Care should be taken to avoid producing muscle contractions with electrical stimulation in all circumstances where muscle contraction may disturb the healing process e.g. recent surgical procedures, repetitive strain injury, fresh fractures.
For sensory stimulation place the electrodes so as to surround the area to be stimulated.
26
27
Recommended electrical stimulation treatment sites and/or parameters

Muscle contractions Electrical stimulation produces muscle contractions by applying a current with sufficient amplitude and duration to depolarize the motor nerve innervating a muscle or group of muscles. This type of stimulation only produces contractions in innervated muscles. Electrically stimulated muscle contractions may be used for muscle strengthening, muscle endurance training, maintaining or increasing joint range of motion, as a substitute for an orthotic, for functional reeducation, reduction of muscle spasm, enhancement of local circulation or prevention of deep venous thrombosis formation after surgery.
Recommended parameters for electrical stimulation

Waveform Pulse duration Pulsed biphasic 150 200 s for small muscles Russian The duration for Russian cannot be set.
Frequency On/off times Ramp times Amplitude Treatment time
200 350 s for large muscles 35 80 pps 50 Hz 2 10 sec. on 2 120 sec. off At least 1 sec. To contraction Sufficient to produce the desired number of muscle contractions to achieve the goals of treatment.
28
29
Muscle strengthening: Quadriceps
Muscle strengthening: Triceps
Waveform Pulse duration
Pulsed biphasic 200 350 s
Russian The duration for Russian cannot be set. 35 80 pps 50 Hz 6 10 sec. on 50 120 sec. off At least 2 secs. To > 10% of MVIC in injured > 50% of MVIC in uninjured 10 20 min to produce 10 20 reps
Russian The duration for Russian cannot be set. 35 80 pps 50 Hz 5 10 sec. on 6 10 sec. on 50 120 sec. off 0 120 sec. off At least 2 secs. To > 10% of MVIC in injured > 50% of MVIC in uninjured 10 20 min to produce 10 20 reps
30
31
Muscle re-education: Wrist extension
Muscle re-education: Ankle dorsiflexion
Russian The duration for Russian cannot be set. 35 50 pps 50 Hz Depends on functional activity At least 2 secs. Sufficient for functional activity Depends on functional activity
Russian The duration for Russian cannot be set. 35 50 pps 50 Hz Depends on functional activity At least 2 secs. Sufficient for functional activity Depends on functional activity
32
33
Muscle spasm reduction: Low back
Muscle spasm reduction: Upper trapezius
Russian The duration for Russian cannot be set. 35 50 pps 50 Hz 2 5 sec. on 2 5 sec. off At least 1 sec. To visible contraction 10 30 min
34
35
Pain modulation (TENS)

Electrical stimulation for pain management Two mechanisms are thought to underlie the efficacy of electrical stimulation for pain management: gate control and opiate-mediated control. Conventional (high-rate) TENS is thought to modulate pain via gate control. Acupuncture-like (low-rate) TENS is thought to modulate pain via opiate mediated control. Conventional (high-rate) mode: Generally used for acute pain Waveform Pulsed biphasic Interferential Pulse duration 50 80 s The duration for intereferential cannot be set independently. It is related to the inverse of the carrier frequency. Frequency 100 150 pps 100 150 Hz Treatment Throughout the duration of pain. duration May be used 24 hrs/day if necessary. Modulation Use if available Amplitude To produce tingling
Acupuncture-like (low-rate): Typically used for chronic pain

Waveform Pulse duration Pulsed biphasic Interferential 200 300 s The duration for intereferential cannot be set independently. It is related to the inverse of the carrier frequency. 2 10 pps 2 10 Hz 20 30 min None To visible contraction
Frequency Treatment duration Modulation Amplitude
36
37
Low back pain: Acute
Low back pain: Chronic
Pulsed biphasic Interferential 50 80 s The duration for intereferential cannot be set independently. It is related to the inverse of the carrier frequency. 100 150 pps 100 150 Hz Throughout the duration of pain. May be used 24hrs/day if necessary. Use if available To produce tingling
Pulsed biphasic Interferential 200 300 s The duration for intereferential cannot be set independently. It is related to the inverse of the carrier frequency. 2 10 pps 2 10 Hz 20 30 minutes None To visible contraction
38
39
Sciatica: Acute
Sciatica: Chronic
Frequency Treatment duration Modulation
Pulsed biphasic Interferential 50 80 s The duration for intereferential cannot be set independently. It is related to the inverse of the carrier frequency. 100 150 pps 100 150 Hz Throughout the duration of pain. May be used 24hrs/day if necessary. Use if available
Pulsed biphasic Interferential 200 300 s The duration for intereferential cannot be set independently. It is related to the inverse of the carrier frequency. 2 10 pps 2 10 Hz 20 30 minutes None
40
41
Cervical radicular pain: Acute
Cervical radicular pain: Chronic
Pulsed biphasic Interferential 200 300 s The duration for intereferential cannot be set independently. It is related to the inverse of the carrier frequency. 2 10 pps 2 10 Hz 20 30 minutes None
42
43
Knee pain: Acute
Knee pain: Chronic
Pulsed biphasic Interferential 200 300 s The duration for intereferential cannot be set independently. It is related to the inverse of the carrier frequency. 2 10 pps 2 10 Hz 20 30 min None
44
45
Tissue healing and edema control

Tissue healing Electrical stimulation can accelerate the healing of chronic wounds including pressure ulcers, vascular ulcers and neuropathic ulcers. The proposed mechanisms for this effect include attraction of appropriate cell types to the area, activation of these cells by alteration of cell membrane function, modification of the endogenous electrical potential of the tissue in concert with healing potentials, reduction of edema, enhancement of antimicrobial activity and promotion of circulation. Negative polarity high-voltage pulsed current (HVPC) is most effective during the inflammation phase of healing and positive polarity HVPC is most effective during the proliferation phase of healing. Recommended parameters for tissue healing Waveform Pulse duration Frequency Polarity Amplitude Treatment time HVPC Fixed at 40 100 s 60 125 pps Negative during inflammatory phase. Positive during proliferation phase To produce comfortable tingling 45 60 min
Sacral pressure ulcer: Inflammatory phase
Waveform Pulse duration Frequency Polarity Amplitude Treatment time
HVPC Fixed at 40 100 s 60 125 pps Negative To produce comfortable tingling 45 60 min
46
47
Sacral pressure ulcer: Proliferation phase
Acute edema due to inflammation

When there is acute edema due to inflammation, indicated by swelling, warm and red skin, and local pain, treatment is directed at repelling negatively charged blood cells and plasma proteins. This, in turn, results in flow of fluid away from the swollen and inflamed area. Electrical stimulation can produce this effect by use of a high voltage pulsed current (HVPC), with sufficient pulse duration and amplitude to produce sensation but not a muscle contraction, with the negative polarity electrode placed over the swollen and inflamed area. Recommended parameters for controlling acute edema due to inflammation Waveform Pulse duration Frequency Polarity Amplitude Treatment time HVPC Fixed at 40 100 s 100 120 pps Negative To produce comfortable tingling 20 30 min
HVPC Fixed at 40 100 s 60 125 pps Positive To produce comfortable tingling 45 60 min
48
49
Acute edema due to inflammation: Knee
Acute edema due to inflammation: Ankle
50
51
Chronic edema due to lack of motion

Electrical stimulation is generally used to increase local circulation when edema is present. When there is chronic edema due to lack of motion present, indicated by swelling and cool and pale skin, treatment is directed at increasing the activity of the muscles around the venous system. Intermittent contraction of these muscles can help pump fluid through the veins from the periphery to reduce peripheral swelling. Intermittent electrical stimulation of the motor nerves can be used to produce such intermittent muscle contractions. Recommended parameters for controlling chronic edema due to lack of motion Waveform Pulse duration Pulsed biphasic 150 350 s Russian The duration for Russian cannot be set. 35 50 pps 50 Hz 2 5 sec. on 2 5 sec. off At least 1 sec. To visible contraction 10 30 min
Chronic edema due to lack of motion: Foot and ankle
52
53
Chronic edema due to lack of motion: Hand and wrist
Laser and Light

Introduction to laser light therapy What is laser light therapy? Light is electromagnetic energy in the visible or near visible part of the electromagnetic spectrum. Electromagnetic spectrum Light of a specific or narrow range of frequencies can be produced by a laser, a supraluminous diode (SLD) or a light-emitting diode (LED). Supraluminous diode/light-emitting diode/laser Lasers produce light that is of one frequency only (monochromatic), coherent (all the waves are in sync) and, directional (non-divergent). SLDs and LEDs produce light with a narrow range of frequencies that is not coherent and that is slightly divergent. Coherent and directional light Laser light therapy is the application of light from a laser, an SLD or an LED to the body for therapeutic benefit.
Laser
Regular light source
54
55
How laser light works

Laser light therapy works by photobiomodulation. The light is absorbed by chromophores in cells. This can increase the production of adenosine triphosphate (ATP) by mitochondria, increase the production of ribonucleic acid (RNA) specific for collagen synthesis, alter prostaglandin synthesis, alter serotonin and endorphin metabolism and reduce nociceptor activity. Together, these effects help to control pain and inflammation and promote tissue healing.
Coherent vs. non-coherent light Coherent Non-coherent
Laser light parameters explained

Wavelength: The length of each cycle of the electromagnetic wave. The wavelength of the light affects its color and depth of penetration, the longer the wavelength the greater the depth of penetration. Wavelength is generally measured in nanometers (nm, 10-9) and, for most therapeutic lasers, ranges from around 600 nm to around 1,000 nm to produce red or infra-red light.
56
57
Power: The amount of electromagnetic energy per unit time, usually measured in mW (milliWatts). The power of a laser light device is preset on each applicator and generally ranges from 5 to 500 mW. Some applicators produce a higher total power by containing a cluster of multiple lower powered diodes. Some devices can produce a lower total power from an applicator by pulsing the output. Energy: The total amount of electromagnetic energy delivered over the entire treatment time. Energy is generally measured in J (Joules). Energy is power multiplied by time. 1 J = 1 W 1 sec Therefore, the higher the power of the applicator the shorter the treatment time to deliver the same amount of energy. Energy density: The total amount of electromagnetic energy delivered to an area over the entire treatment time. Energy density is generally measured in J/cm2 (Joules per centimeter squared). Most authors agree that this should be the standard measure of treatment dose. Most treatments use 2 30 J/cm2.
Contraindications for the application of laser light therapy 1. Irradiation of the eyes: the patient and the clinician should always wear protective eyewear when treating with a laser device. 2. Cancer 3. Within 4 to 6 months after radiotherapy 4. Areas of hemorrhage 5. Irradiation of endocrine glands Precautions for the application of laser light therapy 1. Low back or abdomen during pregnancy 2. Epiphyseal plates in children 3. Impaired sensation 4. Impaired mentation 5. Photophobia or abnormally high sensitivity to light 6. Pretreatment with one or more photosensitizer
58
59
Suggested laser light treatment sites and parameters Lateral epicondylitis
Arthritis: Knee
Wavelength Color Energy density
620 690 nm Red 2 20 J/cm2
700 1,000 nm Infrared 2 8 J/cm2
60
61
Arthritis: Wrist
Sciatica: Acute
700 1000 nm Infrared 2 8 J/cm2
62
63
Sciatica: Chronic
Cervical radicular pain: Acute
64
65
Cervical radicular pain: Chronic
Thigh hematoma
700 1,000 nm Infrared 10 20 J/cm2
620 690 nm Red 5 16 J/cm2
66
67
Sacral pressure ulcer: Superficial
Sacral pressure ulcer: Deep
620 690 nm Red 5 16 J/cm2
700 1,000 nm Infrared 5 16 J/cm2
68
69

Physical Agents

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Physical Agents

Uploaded by

Copyright:

Available Formats

Copyright 2013, 2009, 2003 by Saunders, an imprint of Elsevier Inc.

Electrical Stimulation, Ultrasound, and Laser Light Handbook

How to use this handbook

Copyright 2013, 2009, 2003 by Saunders, an imprint of Elsevier Inc.

Copyright 2013, 2009, 2003 by Saunders, an imprint of Elsevier Inc.

Copyright 2013, 2009, 2003 by Saunders, an imprint of Elsevier Inc.

Copyright 2013, 2009, 2003 by Saunders, an imprint of Elsevier Inc.

Clinical application of ultrasound

Ultrasound gel or lotion

Copyright 2013, 2009, 2003 by Saunders, an imprint of Elsevier Inc.

Continuous < 2 cm 3 MHz 5 10 min 0.5 W/cm2

20% < 2 cm 3 MHz 5 10 min 0.5 1.0 W/cm2

Copyright 2013, 2009, 2003 by Saunders, an imprint of Elsevier Inc.

Recommended ultrasound treatment sites and parameters Knee contracture

Duty cycle Frequency

Duty cycle Frequency Duration (2 x ERA) Intensity

Continuous 3 MHz 5 10 min 0.5 W/cm2

Duration (2 x ERA) 5 10 min Intensity 1.5 2.0 W/cm2

Copyright 2013, 2009, 2003 by Saunders, an imprint of Elsevier Inc.

Low back pain: Increase circulation

Lateral collateral ligament (LCL) sprain

Duty cycle Frequency

Duty cycle Frequency Duration (2 x ERA) Intensity

20% 3 MHz 5 10 min 0.5 1.0 W/cm2

Duration (2 x ERA) 5 10 min Intensity 1.5 2.0 W/cm2

Copyright 2013, 2009, 2003 by Saunders, an imprint of Elsevier Inc.

Sacral pressure ulcer

Duty cycle Frequency

Duration (2 x ERA) 5 10 min Intensity 0.5 1.0 W/cm2

Copyright 2013, 2009, 2003 by Saunders, an imprint of Elsevier Inc.

Electrical stimulation parameters

Current strength (mA)

A Sensory Motor A Sharp pain

C Dull pain Denervated Muscle

20 0 10 40 100 300 600 Microseconds ( sec) 1.0 10 Milliseconds (msec) 100

Pulse duration (pulse width)

Copyright 2013, 2009, 2003 by Saunders, an imprint of Elsevier Inc.

Copyright 2013, 2009, 2003 by Saunders, an imprint of Elsevier Inc.

0 Time - polarity - polarity

Copyright 2013, 2009, 2003 by Saunders, an imprint of Elsevier Inc.

Copyright 2013, 2009, 2003 by Saunders, an imprint of Elsevier Inc.

Motor point biceps brachii

Copyright 2013, 2009, 2003 by Saunders, an imprint of Elsevier Inc.

Recommended electrical stimulation treatment sites and/or parameters

Recommended parameters for electrical stimulation

Frequency On/off times Ramp times Amplitude Treatment time

Copyright 2013, 2009, 2003 by Saunders, an imprint of Elsevier Inc.

Muscle strengthening: Quadriceps

Muscle strengthening: Triceps

Waveform Pulse duration

Pulsed biphasic 200 350 s

Frequency On/off times Ramp times Amplitude Treatment time

Waveform Pulse duration

Pulsed biphasic 200 350 s

Frequency On/off times Ramp times Amplitude Treatment time

Copyright 2013, 2009, 2003 by Saunders, an imprint of Elsevier Inc.

Muscle re-education: Wrist extension

Muscle re-education: Ankle dorsiflexion

Waveform Pulse duration

Pulsed biphasic 150 200 s

Frequency On/off times Ramp times Amplitude Treatment time

Waveform Pulse duration

Pulsed biphasic 150 200 s