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 Proven Modalities that Pay
for Themselves:
Electrotherapy, Laser, and
Ultrasound

Written and Presented by:

David Draper EdD, ATC

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Proven Modalities that Pay for Themselves:

Electrotherapy, Laser, and Ultrasound

David Draper, EdD, ATC

Cross Country Education

Leading the Way in Continuing Education and Professional Development
www.CrossCountryEducation.com
Electrotherapy in Physical
Medicine & Rehabilitation
„ Dr. David O. Draper, ATC, LAT
„ Professor, Researcher, Author
Brigham Young University,
Provo, Utah

„ David_draper@byu.edu

emails

David_draper@byu.edu

ELECTRICAL STIMULATION
OBJECTIVES

RIdentifyTerms used with

Electrical Stimulation
RUnderstand various types of
electrodes
RRecognize Indications/
Contraindications of Electrical
Stimulation

1
 ELECTRICAL STIMULATION
CLINICAL APPLICATIONS

R Pain Management
R Muscle Re-education:
1) For Tone Reduction
2) To Maintain - Improve ROM
3) For Muscle Strengthening
4) Treatment of Disuse Atrophy
R Increase Blood Flow - Reduce
Edema

ELECTRICAL STIMULATION
PARAMETERS

ROutput Current and Voltage

RType of Current
RPulse Rate, Burst Rate,
Modulation
RPulse Duration

RRamp Times

ROn-Off Time

RProper Electrode Placement

(IAPT BS1, BS8, BS9)

Basics of Electricity
„ Must understand why as well as how to
use electrical stimulation.
Or
„ You䇻ll be a knobologist (One who knows
application without theory).

2
Volt

„ The electromotive
force required to
produce a
movement of
electrons.

AMP: Rate of current flow

„ 0-1 mA ……………imperceptible
„ 1-15mA…………….tingling sensation
„ 15-30mA……………muscle contraction
„ 30-100mA…………..painful electric
shock
„ 100-200mA…………cardiac/resp. arrest
„ >200mA……………tissue
burn/destruction

Ohm
„ Resistance to electron (current) flow
– Determined by:
– Type of material
– Length of material
– Cross sectional size of material
– Temperature of circuit

3
Strength-Duration Curve

As intensity is increased,
the current goes deeper.

Electrotherapy in a
nutshell:
define:
„ Current
„ Waveform
„ Current modulation:
– Pulse
– Pulse duration
– On/Off time
– Ramp
„ Circuit

4
Electrotherapy in a
nutshell:
define:
„ Current: The flow
of electrons.

Electrotherapy in a
nutshell:
define: Direct Current
„ Continuous flow of
electrons in one
direction. Electrons
travel from the
negative pole
(cathode) to the
positive pole (anode).
„ Galvanic: uninterrupted
DC
„ Monophasic:
interrupted DC

Commonly Used Wave

Forms (cont.)
„ Direct (galvanic)
wave form
– Pure DC current,
used for
iontophoresis

5
Electrotherapy in a
nutshell:
define: Alternating current
„ Current flow that
periodically changes
its polarity or
direction of flow.
„ Goes back & forth

Commonly Used Wave

Forms
„ Sinusoidal wave
form
– Pure AC current

Electrotherapy in a
nutshell:
define:
„ Current
„ Waveform: The
shape, direction,
amplitude and
duration of an
electric current.
„ (sine, square,
rectangular,
sawtooth
„ Or triangular, & spike)

6
Commonly Used Wave
Forms
„ Modulation of DC and AC currents
produce a variety of output forms
„ Most common output wave forms
described on following slides

Electrotherapy in a
nutshell:
define:
„ Current
„ Waveform
„ Current modulation:

Current Modulation
„ Includes all manipulating, regulating and
adjusting to create a variety of specific
output wave forms.
„ Most output is pulsed or as AC trains
„ Factors modulated
– shape
– duty cycle {on/off}
– timing
– amplitude

7
 Electrotherapy in a
nutshell:
define:
„ Current
„ Waveform
„ Current modulation:
„ Pulse: An individual
waveform

Pulse & Cycle

Characteristics
„ Pulse: finite period of charged particle
movement, separated from other pulses
by a finite time during which no current
flows
„ Made up of one or more phases
Phase Inter Pulse Interval

Pulse 2nd Pulse

Pulse and Cycle Characteristics (cont.)

„ Pulse named by number

of phases
– Monophasic
„ One phase
„ Current flows in one
direction only.
– Biphasic
„ Two phases
„ Current flows in both
directions.
– Polyphasic
„ Many phases

8
 Phase and Pulse Charge
„ Train
– A continuous repetitive series of pulses at a fixed
frequency
– Polyphasic
– 䇾pure䇿 AC

Train and burst

characteristics
„ Burst
– Finite series of pulses flowing for a finite time period
followed by no current flow
„ Think of it as turning a pulse train or AC current on and off

„ Burst interval
– Time during which burst occurs
„ Interburst interval
– Time between bursts, usually in milliseconds

Modulated amplitude

9
Electrotherapy in a
nutshell:
define:
„ Current
„ Waveform
„ Current modulation:
– Pulse
– Pulse duration
– On/Off time
– Ramp
„ Circuit

Electrotherapy in a
nutshell:
define:
„ Current
„ Waveform
„ Pulse
„ Pulse duration: The
length of a pulse

Pulse duration (cont.)

„ As we increase the
pulse duration
(width) more fibers
are stimulated.

10
Duration of wave or pulse
(pulse width)
„ A short pulse duration will stimulate
few nerve fibers
„ By increasing the pulse duration or
width, we can stimulate more nerve
fibers, since the current is available for
a longer period of time.

Current Timing
Modulation
„ Pulse Width (Pulse Duration)
– Time required for each pulse to complete its
cycle
– Reported in micro- or milliseconds
„ Short pulse duration <150 microseconds.
„ Long pulse duration > 200 microseconds.
„ Interpulse Interval
– Time between successive pulses

Train and burst

characteristics
Duty Cycle
– Ratio of time on vs. total time
„ Thus current with an on time of 10 msec and
an off time of 40 msec would have a 20%
duty cycle

11
Electrotherapy in a
nutshell:
define:
„ Current
„ Waveform
„ Pulse
„ Pulse duration
„ On/Off time: The
amount of time the
current is flowing.

„ Time on
– Time during which current flows; from
the beginning to the end of a surge.
„ Time off
– Time during which current does not flow;
time between surges.

Electrotherapy in a
nutshell:
define:
„ Current
„ Waveform
„ Current modulation:
– Pulse
– Pulse duration
– On/Off time
– Amplitude
– Ramp
„ Circuit

12
 Current Amplitude
Modulation
„ Amplitude (intensity,
output)
– Measured in two ways
„ Voltage delivered to the
electrodes
„ Current flowing through the
circuit
„ Peak Current
– Highest magnitude of the
pulse

Electrotherapy in a
nutshell:
define:
„ Current
„ Waveform
„ Pulse
„ Pulse duration
„ On/Off time
„ Ramp: A gradual
increase or
decrease in the
intensity of the
current

Ramp {Surge} Characteristics

„ Ramp Up
– Time during which the intensity increases
„ Plateau
– Time during which pulses remain at maximum preset
intensity
„ Ramp Down
– Time during which the intensity decreases

13
Electrotherapy in a
nutshell:
define:
„ Current
„ Waveform
„ Pulse
„ Pulse duration
„ On/Off time
„ Ramp
„ Circuit: The path of a
current from a
generating source
through the various
components, back to
the generating source.

The path of an electrical

current

The Body Circuit: The human body is a mass of

tissues and fluids, each of which has a varying
ability to conduct electrical currents. The
electrical conductivity of a tissue is directly
related to its water content. The higher the
water content, the greater the ability to conduct
electricity.

14
Excitable tissues (70-75% water)
-nerve fibers
-muscle
-blood
-secretatory cells

Non-excitable tissues (20-30% water)

-bone cartilage
-tendons
-ligaments

FREQUENCY

„ The number of
pulses per second
„ LF = < 1000 pps
„ MF = 1000-10K pps
„ HF = > 10,000 pps

FREQUENCY (carrier)

„ The frequency that

is programmed into
the device.

15
FREQUENCY (beat)
„ Controls the amount of
shortening and
recovery allowed the
muscle fiber.
„ 1 beat is called a
twitch contraction.
„ Question: What
happens when the
number of twitch
contractions per sec.
increases to 15 HZ?

FREQUENCY (beat)
(cont.)
„ ANSWER:
„ Tetany (this is used
to produce a strong
contraction and
produce tension in
the muscle)

Question: What are 3

ways to increase the
number of nerve fibers
being stimulated, and
thus produce a stronger
contraction?

16
Question: What are 3 ways to
increase the number of nerve
fibers being stimulated, and thus
produce a stronger contraction?
„ Increase the intensity of
pulses
„ Increase the frequency of
pulses
„ Increase the width/duration
of pulse(s)

Electrodes: (Must contain many

free electrons)

„ The site where the

electrodes touch
the skin serves as a
point of conversion
between flow of
electrons from
generator to flow of
ions in the body
tissues.

Types of electrodes:

„ Metallic mesh cloth

„ Carbon rubber
„ Metal

„ Mediums: gel or
sponge and water

17
Electrodes (cont.)
„ Cross-contamination of reusable electrodes

Electrodes
„ Top: adhering
electrode that can
be used 10 times

„ Bottom: single-use
electrode

Methods of reducing
skin electrode resistance
„ Moisten electrodes „ Remove excess hair
with water or gel „ Saturate sponges
„ Cleanse the skin (if used)
„ Warm area with „ Use silver
moist heat pack electrodes
„ Gently scrub area
with fine emery
paper

18
Electrode Placement

Electrode proximity

Bipolar electrode
placement
„ Equal size
electrodes
„ Equal current
density
„ Can split leads so
each channel has 2
electrodes
„ Best for muscle
pump/contraction

19
Monopolar electrode
placement
„ Large dispersive
electrode
„ Small active
electrode
„ Use to identify
motor points
„ Iontophoresis
„ Combination
therapy

Quadripolar electrode
placement
„ 2 sets of electrodes
from own channel
„ Parallel placements
(spine and
dermatome)
„ Agonist placements
„ Interferential
current

ELECTRICAL STIMULATION
CONTRAINDICATIONS
(IAPT NM56-58)

R Pacemaker
R Cancer (with active tumor)
R Stimulation transcerebrally, transcranially
R Danger of hemorrhage immediately following
injury
R Transthoracic stimulation
R Patients with epilepsy should be monitored
R Do not apply muscle stimulation in the
immediate vicinity of healing tissue.

20
THE END:
ELECTROTHERAPY 101

Electrical Stimulation
Application Procedures
Part Two

Electrical Currents: An
Overview
„ Used therapeutically since the ancient
Greeks with electric eels
„ After a torpedo fish, or electric ray was
applied against a patient䇻s skin, the
pain from gout went away. (time of Christ)

21
Use of Electrical Current
Stimulation for Pain Relief
„ Transcutaneous Electrical Nerve
Stimulation (TENS)
„ Interferrential Current Therapy (IFC)
„ Iontophoresis
„ Neuromuscular electrical stimulation

Use of Electrical Current

Stimulation for Pain Relief
„ TENS
– Transcutaneous -
䇾through the skin䇿
– Electrical
– Nerve - sensory
– Stimulation -
depolarize
„ stimulate sensory
nerves w/ pulsed
current via surface
electrodes

TENS, a short history

„ Began in the early 1970's

„ Melzack and Wall
„ Gate theory (stimulating afferent nerves
could close the gate in the spinal column to
pain signals coming from other nerves)

22
Physiological aspects of
TENS
„ Electrode placement (usually at the site of pain)
„ Clinician can change the patient䇻s
perception of acute and chronic pain
„ Selective depolarization of afferent
nerves

Electrically induced nerve

depolarization
„ Nerves are excitable structures and
the passage of pulsed currents
through such nerves can depolarize
them. Nerve fibers at rest are
polarized with the inside of their
membranes being negatively charged.

Continued

„ To depolarize a nerve means to

reverse this polarized state, causing
the inside of the nerve membrane to
become positively charged. The
reversal of potential across the nerve
semipermeable membrane leads to
formation of an action potential, or
nerve impulse.

23
 All or none principle

„ All action potentials, for a given nerve

are the same size Therefore we have 2
possibilities—either the nerve
threshold for depolarization is not
achieved, zzz9no action potential) or
the threshold is achieved (full action
potential generated –all)

Nerve refractory period

„ Within the refractory period, with lasts

less than 1 ms, there is an absolute
period during which it is impossible to
depolarize the nerve, and a relative
period during which an action
potential can be generated if one
applies an electrical pulsed having a
greater amplitude.

How does TENS work?

„ Many theories
„ Gate system and sensory TENS
– 80 to 150pps

24
Pathway through the
body

Types of sensory nerve fibers

„ Pain:
A delta: larger, slightly myelinated, faster
{instant pain, withdrawl, acute}

– C: small, nonmylenated, slow. {throbbing,

pressure, chronic pain}

Types of sensory nerve fibers

– Sensory & Proprioceptive:

- A Alpha and A ǃ- (beta): Large, myelenated,
fastest {non-painful stimuli}

25
 Gate Control Theory of
Pain
„ Integrates the specificity & pattern
theories
„ Operates at the spinal level
„ Proposes a "gate" mechanism
– Located in the dorsal horn
– Allows only one sensation at a time to
pass through to the brain

Gate closing

„ Research has shown that the gate

closing is associated with the
preferential evoked activity or
depolarization of the periferal A-beta
fiber over the smaller-diameter A-delta
and C fibers

Endogenous Opiate System

„ Opiate system
– Motor TENS and brief-
intense TENS
„ Beat frequency Varies
from low to high
„ Intensity to patient
tolerance
Enkephalin thought to
block pain gate by
interfering with A delta
and C fiber transmission
to 䇾T䇿 cells. (high
intensity TENS)

26
Endogenous Opiate System
„ Opiate system
– Motor TENS and brief-
intense TENS
„ Low beat frequency 1-
5pps
„ Slight muscle twitch
Beta Endorphin thought to
inhibit pain signal
transmission & decrease
chemical irritants in
CNS. (Motor TENS)

Endogenous Opiates
(cont)
„ These are
secreted from
the suffering
patient䇻s blood
plasma and
cerebrospinal
fluid.

TENS: Physiological
Aspects
„ Electrode placement
– Usually at the site of
pain
„ Clinician can change
the patient䇻s
perception of acute
and chronic pain.
„ Selective
depolarization of
afferent nerves

27
 Evidence

„ Anything that
establishes a fact
or gives a reason
to beleive
something

General pain relief

Oosterhof; 2006
Deneger; 1989
Buxton; 1994
Kuhn; 2010
Cheing; 2002
Brown; 2009
Yeh; 2010

Postoperative
abdominal pain
Cooperman, 77
Vander Ark, 75
Smith, 86
Hargreaves, 89
Hoolinger 86
Chen, 98
Hamza, 99
And several others

28
Low back pain
„ Bertalanffy, 05
„ Deyo, 90
„ Marchand, 93
„ Pope, 94
„ Harrison, 87
„ Bates, 80
„ Magora, 83
„ And many others
„ Olsen, 07
„ Keenan, 85
„ And many others

Labor and post-labor pain

„ Olsen, 07
„ Bundsen, 81,82
„ Augustinsson 77
„ Kaplan, 98
„ Bortoluzzi, 89
„ and many others

Postoperative thoracic
pain
„ Carrol, 01
„ Bavindir, 91
„ Navathman, 84
„ Warfiield, 85
„ Benedetti, 97
„ Erdogan, 2006
„ And many others

29
Chronic pain syndrome

„ Bates, 80
„ Fishbain, 96
„ Koke, 04
„ Meyler, 94
„ Abram, 81
„ Tulgar, 91
„ And many others

Osteoarthritis pain

„ Cheing, 03
„ Zizic, 95
„ Lewis, 84
„ Brimmer, 92
„ Smith, 83
„ Taylor, 81
„ And many others

Osteoarthritis pain

„ Cheing, 03
„ Zizic, 95
„ Lewis, 84
„ Brimmer, 92
„ Smith, 83
„ Taylor, 81
„ And many others

30
 Brief research findings on
TENS
„ Research is difficult
„ TENS has relieved pain associated
with:
– Osteoarthritis
– Rheumatoid arthritis
– Dysmenorrhea
– Low back pain
„ Post-operative TENS

Reimbursement for TENS

„ Code 97014
„ Application of a modality to one or more areas;
electrical stimulation (unattended).
„ The provider applies electrical stimulation to one or
more areas in order to stimulate muscle function,
enhance healing, and alleviate pain and/or edema.
The clinician chooses which type of electrical
stimulation is appropriate. The treatment requires
supervision and typically only one unit is billed per
day.

Interferential Current Therapy

(IFC)

„ Interference or superimposition of two

separate medium frequency sinusoidial
currents upon one another.
„ Symmetrical, sinusoidal, medium
frequency (2000-5000 Hz) AC
„ Invented in 1950. Came to U.S. in
early 80䇻s.
„ 5th most frequently used physical
agent.

31
 Purpose

„ Provide practitioners with yet another

type of electrical current that could
penetrate deeper into the tissues with
minimum discomfort or pain for the
patients.

IFC (cont.)

„ Two channels with

different
frequencies, used
simultaneously
„ Two currents
cause a tissue
current amplitude
modulation

IFC
„ Interferential wave form
– Symmetrical, sinusoidal, high frequency (2000–5000 Hz) AC

– Two channels, with different frequencies, used simultaneously

– Two currents cause a tissue current amplitude modulation

32
 Interferential Therapy
The basic principle of Interferential Therapy (I/F)
is to utilise the strong physiological effects of low
frequency (@ <250pps) electrical stimulation of
muscle and nerve tissues without the associated
painful and somewhat unpleasant side effects of
such stimulation.

Interferential Therapy (cont.)

To produce low frequency effects at sufficient intensity

and depth, most patients experience considerable
discomfort in the superficial tissues (i.e. the skin). This is
due to the resistance (impedance) of the skin being
inversely proportional to the frequency of the stimulation.
In other words, the lower the stimulation frequency, the
greater the resistance to the passage of the current & so,
more discomfort is experienced. The skin impedance at
50Hz is approximately 3200ȍ whilst at 4000Hz it is
reduced to approximately 40ȍ . The result of applying this
latter frequency is that it will pass more easily through the
skin, requiring less electrical energy input to reach the
deeper tissues & giving rise to less discomfort.

Why use Interferential

Current Therapy?

„ Pain reduction and edema

management
„ Bone stimulation
– Uses a medium frequency current as its
carrier frequency
– Less resistance by the skin while being
able to generate a more comfortable
current

33
 How does IFC work?

„ 2 channels
„ 4 electrodes in a
criss-cross pattern
– Pain centered in the
middle
„ Set intensity so
patient feels
tingling without
contracting

Interferential Current
Therapy

„ Four electrodes in a
criss-cross pattern
– Two electrodes from
one channel
– Two electrodes from
another
– Where two currents
cross or interfere is
called a vector

Interferential Current
Therapy

„ Advantages of the „ Figures 10.14 and .15

vector pattern
– Surface and deep
stimulation
– Targeted tissues
for added benefit
– Treatment of easily
localized pain
– Treatment of large
areas
– Treatment of
poorly defined pain

34
How does IFC work?
„ Eg. One channel
runs at 5000Hz
another at 5100 Hz
„ Use a dynamic
vector (or scan for poorly
defined pain)
„ Use target for easily
localized pain
„ Treating most of
the area bracketed
by the electrodes
(scan or dynamic vector)

Is IFC therapy effective?

„ Differing opinions on effectiveness

„ General pain relief:
„ --Johnson; 2001
„ --McLoda; 2000
„ --Kloth; 1992
„ --Ozcan; 2004
„ --Hobler; 1991

Evidence for IFC use

„ Pelvic muscle weakness/urinary

incontinence
„ Henell, 87
„ Turkan, 05
„ Wilson, 87
„ Olah, 90
„ Dumoulin, 95
„ And many others

35
Osteoarthritis pain

„ Ni Chiosig, 94
„ Shafshak, 91
„ Hurley, 01
„ Adedoyin, 02

Is IFC therapy effective?

„ Those who have had success

– Correctly position the vector
– Appropriate size and positioning of
electrodes
– Use appropriate stimulation parameters
– Persevere if the onset and duration of
pain relief is not obtained

Others

„ Bone fracture healing: Ganne,88,79

„ Low-back pain: Zambito,07, 06,
Hurley, 01
„ Migrane: Truscott, 84
„ Postsurgical knee pain: Jarit, 03
„ Dysmenoria: Tugay, 07
„ Quadriceps femoris weakness:
„ Bircan, 02

36
Reimbursement for IFC
„ Code 97014
„ Application of a modality to one or more areas;
electrical stimulation (unattended).
„ The provider applies electrical stimulation to one or
more areas in order to stimulate muscle function,
enhance healing, and alleviate pain and/or edema.
The clinician chooses which type of electrical
stimulation is appropriate. The treatment requires
supervision and typically only one unit is billed per
day.

Electrical Current
Stimulation for Muscle
Contraction
„ Neuromuscular Electrical Stimulation
„ Used for
– Muscle re-education and prevention of
disuse atrophy
– Decreasing muscle spasm
– Decreasing edema

History of NMES

„ Originally used to increase muscle

strength in trained athletes
„ 1977 Russian physiologist Yakov Kots
„ 䇾Russian Current䇿
– Up to 30% more force than a voluntary
maximal contraction
– Lasting strength gains of up to 40% in
healthy athletes
– No sensory discomfort

37
Painless current refuted

„ All subjects reported various levels of

sensory discomfort and pain when
subjected to Russian stimulation
current stimulation.

Greater force refuted

„ Only one study by Selkowitz (1985)

supports Kots䇻s claim of greater
muscle force with RS. Until more
studies support it, this claim must be
refuted.

Lasting strength claims

supported.
„ There is ample evidence to support
Kots䇻s claims that sole application of
electrically evoked muscle training
using not only RS, but other types of
pulsed current waveforms leads to
lasting strength gains in healthy
people

38
History of NMES

„ 1980 companies started

manufacturing Russian current
„ No North American scientist has been
able to duplicate Kots findings
– Great amount of pain (as the current
amplitude was increased to try to replicate a
voluntary muscle contraction).

Purpose: Muscle
strengthening
„ Enhance muscle strenghthening by
maximal electrically evoked
contractions. Improve motor unit
recruitment, while inducing muscle
hypertrophy through a series of bouts
of short duration maximal elecrically
evoked muscle contractions done
against a resistance or load.

Purpose: Muscle
endurance
„ This is done by replacing submaximal
voluntary muscle contractions by
submaximal electrically evoked muscle
contractions. The objective is to
improve the ability to recruit fatigue
resistant muscle fibers through a
series of bouts of longer duration
submaximal electrically evoked
contractions.

39
 Commonly Used Wave
Forms
„ Russian
– Polyphasic, symmetrical, sinusoidal, burst

– Named because developed by Kots, a Russian

scientist
– Initially a 2500 Hz AC current burst-
modulated every 10 msec, now many
frequency choices

Why NMES?

„ Used on patients who cannot perform

a voluntary muscle contraction
(peripheral nerve innervation is intact, yet muscle is
too weak to contract from atrophy, pain,
immobilization, etc.)
„ Promotes early AROM in postsurgical
and immobilized limbs

NMES and Injured Muscle

„ Treatment goals:
assisting with
motion
„ Reeducate muscle
toward normal
motion
„ Facilitate active
exercise
(Used with permission from Castel D.
International Academy of Physio
Therapeutics. Clip art.)

40
 Don䇻t Replace Strength
Training With NMES

„ NMES recruits fibers in the opposite

order than a voluntary contraction
(machine = Fast twitch fatigable & FT glycolytic, = smaller
motor units. VMC = sma;; motor units, fast twitch glycolytic,
and FT fatigue resistant.

„ Patient needs to move on to more

traditional weight training ASAP

Optimal on/off time

„ Optimal on/off „ The more

time is 10 sec/50 fatigable the
sec. This allows muscle is, the
for less muscle shorter the on
fatigue. time or the
longer the off
time.

A. Muscle
contraction
Early rehab
10/50 sec duty cycle

Later: 10/30 sec

duty cycle

41
Body of evidence: Decreasing
muscle weakness

Underwood, 90
Soo, 88
Selkowitz, 85
Pfeifer, 97
Parker, 05
Laufer, 01
Dobsak, 06
And many others

Body of evidence cont.

„ Patellofemoral
synfrome:
Callaghan, 01
„ Post knee sprain
muscle atrophy:
„ Nitz, 87

NMES for Decreasing Muscle

Spasm
„ Cause and mechanism of a muscle spasm is
not clearly defined
„ Result from trauma accumulation of
chemical irritants, muscle weakness and
pain
„ Pain and discomfort lead to more pain and a
protective muscle spasm
„ As the spasm puts pressure on sensitive
nerve endings, more pain is produced
„ 䇾pain-spasm-pain䇿 cycle

42
NMES for Decreasing Muscle
Spasm
„ Goals of the treatment should be to
break up the vicious 䇾Pain-spasm-
pain䇿 cycle
„ 10 sec on; 10 sec off

Tetanic Contraction

„ Goals
– Increase local circulation
– Remove metabolic wastes
– Mechanically stimulate muscle fibers
– Induce some muscle spasm fatigue

NMES for Decreasing

Edema
„ Produce 䇾cyclic䇿 muscle contractions
to help pump chronic edema(5-10 sec on; 5-
10 sec off)

43
Reimbursement for IFC
„ Code 97014
„ Application of a modality to one or more areas;
electrical stimulation (unattended).
„ The provider applies electrical stimulation to one or
more areas in order to stimulate muscle function,
enhance healing, and alleviate pain and/or edema.
The clinician chooses which type of electrical
stimulation is appropriate. The treatment requires
supervision and typically only one unit is billed per
day.

High volt pulsed current

„ HVPC is a perculaneous delivery of

pulsed, twin-peak, monophasic pulses,
each pulse having a very short pulse
duration less than 200 ms. This
employs a high driving peak voltage,
usually higher than 150 volts and up
to 500 volts

Twin peak monophasic

pulse

44
Purpose

„ Primarily used in the field of electrical

stimulation for tissue healing and
repair. More specifically, HVPC is used
to promote and accelerate the healing
process of slow to heal cutaneous
wounds.

Rationale for use:

„ It remains a challenge for practitioners

to electrically stimulate deep excitable
tissue without causing pain. The
challenge is to be able to depolarize
these sensory and motor nerve fibers
without depolarizing pain fibers.

Ratioanle for use Cont.

„ To meet this challenge, the electrical

waveform duration must be very short
and its amplitude very high.

45
History

„ The first HVPC was developed in the

1940䇻s by American scientists at Bell
Laboratories.

Early studies:

„ Young (66) reported that HVPC

decreased limb edema and prevented
gangrene in dogs that had their hind
limb circulation compromised for 12
hours via a tourniquet.

Early studies Cont.

„ Thurman (71) reported what appears

to be the first study on the therapeutic
use of HVPC on humans, reporting
benefit for the treatment of a septic
diabetic abcess in a sigle patient.

46
Uses: Dermal wounds

„ Delivery of HVPC at the wound site is

believed to mimic and augment the
weak endogenous skin battery
voltages, which in turn increase the
amplitude of those currents of injury
thus promoting wound healing.

Theory:

„ The migration of polarized cells toward

the cathode or anode results in
migration of neutrophils,
macrophanges, lymphocytes and
platelets to enhance the inflammatory
phase of healing.

Theory Cont.

„ Migration of fibroblasts enhances the

proliferation phase. Finally migration
of epidermal cells and keratynocytes
facilitates the final phase of healing,
namely the remodeling/maturation
phase.

47
Antiedema effect

„ This is presumed to be caused by

repulsion, under the cathode of
negatively charged albumin proteins
found in the blood, causing a fluid
shift and thus reducing edema at the
electrode site.

Evidence for treating

dermal wounds:
„ Fitzgerald, 93
„ Thurman, 71
„ Goldman, 02
„ Mawson, 93
„ Franek, 2000
„ Akers, 84
„ Griffin, 91
„ And many others

Evidence for
posttraumatic edema:
„ Lamboni, 83
„ Voight, 84
„ Ross, 81
„ Griffin, 90
„ Michlovitz, 88

48
Reimbursement for HVPC
„ Code 97014
„ Application of a modality to one or more areas;
electrical stimulation (unattended).
„ The provider applies electrical stimulation to one or
more areas in order to stimulate muscle function,
enhance healing, and alleviate pain and/or edema.
The clinician chooses which type of electrical
stimulation is appropriate. The treatment requires
supervision and typically only one unit is billed per
day.

Iontophoresis
ಯIontophoresis is probably the most
underutilized, misunderstood and
underestimated modality.ರ
-Scully & Barnes, Physical Therapy

Iontophoresis
„ Iontophoresis is an active
transdermal drug delivery system
that delivers drug ions through the
skin using an electric current.

49
Iontophoresis: Basic Principle
„ Like charges repel like charges,
„ Drug ions are repelled or pushed into the underlying tissue.
„ Two electrodes
– One drug delivery
– One larger dispersive electrode

How Does Ionotophoresis

Work?
„ When an electrical DC current is
applied
– (+) charged electrode delivers (+)
charged drug ions into the skin and
surrounding tissues
– (-) charged electrode delivers (-)
charged drug ions into the skin and
surrounding tissues

Why use
ionotonphoresis?
„ Delivering medicine such as anti-
inflammatories, and pain relievers
directly without the (-) effects of:
– Painful needle injections
– Risk of infection from non-sterile needle
injections
– Systemic effects from taking a pill
„ Mild tingling or warm sensation
during treatment

50
 Drug & Dispersive Electrodes
„ Place the drug delivery electrode over
the area to be treated
„ Place the dispersive pad over
adipose/muscle

Medication
Medication:
„ Must be water-soluble
ƒ Suspensions are not suitable
„ Must be ionized (i.e. charged)
„ Molecular weight should be below ~5,000

Local diffuse dose is delivered to a depth of ~1.7cm

Glass, J.M. et al. 1980 International Journal of Dermatology. 19:519-525

Common Drug Ions Used in

Sports Medicine
„ Dexamethasone: (-) ion
– Reduces inflammation by inhibiting
biosynththesis of prostaglandins and
various other inflammatory substances
„ Acetate: (- ion)
– Assists in dissolving calcium deposits
and scar tissue in soft tissues

51
Common Drug Ions Used in
Sports Medicine
„ Hydrocortisone: (+) ion
– Assists in decreasing tissue inflammation
by inhibiting biosynththesis of
prostaglandins
„ Lidocaine: (+) ion
– Assists in decreasing local pain by
blocking nerve impulse transmission

Mechanism of Action

„ When direct current (DC) is applied to an

ionized drug solution, the ions that have
the same charge as the electrode are
repelled by the electrode and are
delivered through the skin.

Is Iontophoresis
effective?
„ Debate
– Research has shown it to deliver
medication from 6 to 20 mm below the
skin

52
Is Iontophoresis
effective?
„ Effective in reducing pain and
inflammation associated with:
– Plantar faciitis
– Temporomandibular disorders
– Epicondylitis
„ When Dexamethasone, Lidocaine or Sodium
salycilate

Benefits of Iontophoresis
„ Compared to injections:
ƒ Virtually painless
ƒ Non-invasive minimizing:
ƒ Risk of infection
ƒ Risk of tissue necrosis, tendon rupture, etc.

„ Compared to oral medications:

ƒ Localized drug delivery, non-systemic
ƒ Avoid risk of systemic side effects

Quantity of Medication Delivered

References:
1. Glass, J.M. et al. 1980 International Journal of Dermatology. 19:519-525
2. Petelenz, T.J. 1992, Journal of Controlled Release 20:55-66
3. Dosage recommendations for water soluble medications (PDR)

53
Indications

„ Iontophoresis is used to administer

water-soluble ionic medications

Contraindications
„ Damaged or denuded skin
ƒ Recent scar tissue
„ Drug allergies
„ Trans-cranial
„ Orbital region
„ Electrically sensitive support systems
ƒ Pacemakers

Precautions
„ Diabetes
„ Pregnancy
„ Over external metal fixation devices
„ ͆Elderly͇ skin
„ TMJ
ƒ Dizziness
ƒ Metallic taste

54
Drug Dose Calculation
Dosage (mA-min) =
current (mA) x treatment time (min)

Examples:
40mA-min = 4.0mA (current) x 10 minutes (time)
or
40mA-min = 2.0mA (current) x 20 minutes (time)

55
A Research Technique

Sensation of Iontophoresis
„ Some patients feel little or no
sensation; others describe it as a
tingling or warm sensation.
„ The intensity of the sensation varies
between patients and depends on the
site being treated.
„ These sensations usually decrease or
disappear after a few minutes.

Tips For Increasing Comfort

„ Place dispersive electrode over adipose/muscle
„ Avoid sensitive areas of skin
„ Ensure good contact
„ Ensure thorough hydration of electrode
„ Increase current slowly
„ Avoid additional modalities prior to
iontophoresis
„ Do not shave area – only clip hair with scissors
„ Do not tape, bind or compress electrodes

56
 Typical Skin Reactions
„ Direct Current (DC) causes capillary dilatation
leading to erythema (reddening) of skin under
one or both electrodes
„ Another less frequent skin reaction is the
appearance of very small fluid filled bumps
caused by the release of histamine from dermal
mast cells

Note:
These skin reactions disappear over the course of a few
minutes, but may last longer in patients with particularly
sensitive skin. Also, some patients with sensitive skin
may even react to the adhesive on the electrode.

Factors Affecting Skin Reactions

„ Skin type: Fair or sensitive skinned patients will

usually exhibit more skin irritation or sensation.
„ Sensitivity to DC current: DC current can cause
increased redness, as well as the release of
histamine in the skin. In sensitive individuals,
this can lead to the appearance of an allergic
reaction (small white bumps or hives) even
though the patient is not allergic to the drugs
used.
„ Skin pigmentation: In darker skinned patients,
the normal reddening is usually less visible than
with lighter skinned patients.

Negative Effects from

ionotophoresis
„ To help reduce the risk of skin
irritations:
– Clean the skin with an alcohol scrub
– After treatment apply a lotion containing
aloe vera
– Increase the size of the anode or cathode
to decrease current density
– Increase the spacing between electrodes
to decrease current intensity

57
Treatment Procedure
„ Initial steps to prepare for a treatment:
! Read Directions for Use

1. Ask patient about medication, skin

sensitivity, pacemaker, and pregnancy
2. Use large electrodes and/or lower currents
for patients with sensitivity
3. Mention possible erythema and histamine
reaction
4. Trim excessive hair with scissors – never
shave area

Treatment Procedure
„ Preparing for treatment, continued:
! Read Directions for Use

5. Cleanse areas of the skin for the two

electrodes using a standard alcohol wipe
6. Hydrate the drug electrode and place over
area to be treated (intact skin)
ƒ Use larger electrodes and/or lower currents
for patients with sensitivity

Treatment Procedure

„ Placing electrodes for a treatment:

! Read Directions for Use

7. Place the dispersive electrode 4 to 6

inches away from the drug delivery
electrode
8. Connect the dose controller to the
electrodes

58
 Treatment Procedure
„ Performing a treatment:
! Read Directions for Use

9. Set the desired drug delivery dose and

current
10.Treatment generally takes 10 to 15
minutes
11.Dose controller 䇾beeps䇿 when the
treatment is completed

Treatment Procedure
„ Final steps of a treatment:
! Read Directions for Use

12.Disconnect dose controller from the

electrodes
13.Remove the electrodes and dispose
14.Apply any non-irritating, unscented, oil
and grease free, neutral pH skin lotion on
both electrode sites (e.g. aloe vera gel)

Reimbursement for Ionto

„ Code: 97033
„ Application of a modality to one or more
areas; iontophoresis, each 15 minutes.

„ The provider utilizes electrical current to administer

medication to one or more areas. Iontophoresis is
usually prescribed for soft tissue inflammatory
conditions and pain control. This code requires
constant attendance by the clinician and is billed in
multiple 15 minute units.

59
 „The End

Laser & Light Therapy

Dr. David O. Draper, ATC,
FNATA

The Game Plan

„ Characteristics, Terms
and Definitions
„ What is a laser and how
are they classified?
„ How do they work?
„ What are the effects?
Indications
„ Precautions &
contraindications

60
 LASER
„ Originally conceived by Albert Einstein (1917)
„ First laser was developed in 1959 (Malibu, CA).
„ Dermatology, 1963; Therapeutic effects began in
1970’s
„ Laser today is where electrotherapy was in the 1980’s
„ Approved by FDA in 2002 for CTS
„ Used to treat orthopedic injuries, skin conditions,
neurology, and psychological problems such as
depression and S.A.D.

LASER

„ L = Light (electromagneticradiation that produces a visual

sensation)

„ A = Amplify (increase in size, volume, significance), amplify

cell metabolism)

„ S = Stimulate (excite)
„ E = Emission (a flowing forth such as the release of
electrons from parent atoms)

„ R = Radiation (energy transmitted as rays, waves or

particles)

LASER
„ The word laser is used as part of several
related concepts:
„ Laser device: A machine that emits a
laser beam
„ Laser beam: The output of a laser
device
„ Laser light: The light of a laser beam
„ Laser energy: The energy of a laser
beam

61
 LASER
„ Medical lasers produce beams of energy
that can cause either tissue destruction
or therapeutic effects within the tissues.
„ The FDA has approved low level light
therapy (LLLT) for the treatment of
carpal tunnel syndrome and
musculoskeletal shoulder and neck pain;
however, clinically it is used for a wide
range of conditions.
„ What is a “cold laser”? Low intensity

Characteristics
„ Energy source
„ Mechanical structure
„ Lasing medium
– Gas, liquid, crystal, chemical, or
semiconductors (such as LEDs)
– Different lasing medium result in differing
„ Wavelengths
„ Light coherence levels
„ Light divergence levels

Laser Components

„ Four components
– Amplifying chamber
– Lasing medium
– External source of
energy
– Pair of mirrors

62
 LASER
„ Laser light has three main unique
characteristics that differentiate it from
other light sources
„ Monochromaticity: A very narrow band of
wavelengths
„ Coherence: In phase with respect to space
and time
„ Collimation: Narrow beam diameter with no
divergence (opposite of light bulb)

Laser Light Terminology

(cont.)
„ Nondivergent
(coherent)
– Incapable of
separating or
widening
– Contrast the light
from a laser pointer
(nondivergent) with
that coming from a
flashlight
(divergent).

Laser Light vs. Normal

Light
„ Very different
„ Laser light Normal light
– Monophasic Multiphasic
– Monochromatic Multichromatic
– Coherent Incoherent
– Nondivergent Divergent
(directional)

63
Laser Light vs. Normal Light
(cont.)
„ Light from a common light bulb is composed
of waves with different frequencies.

Laser Light vs. Normal Light

(cont.)
„ An LED emits light with waves of the same
frequency (monochromatic) but out of
phase (incoherent)

Laser Light vs. Normal Light

(cont.)
„ A laser emits light with waves of the same
frequency (monochromatic) and in phase
(coherent).

64
Laser Light vs. Normal Light
(cont.)
„ Laser composed of particles of light with
equal energy and of a single phase and
color that move in step with each other

Laser Classification

„ Classified by lasing medium and safety

„ Not classified by wavelength
– But must know wavelength
– Response is specific to wavelength.

Laser Classification by
Medium
„ Gas
„ Diode or semiconductor
„ Dye lasers
„ Solid state
„ Excimer

65
Laser Classification by
Medium (cont.)
„ Gas
– Helium and helium neon (HeNe) most common
„ Diode or semiconductor
– Either small and low powered or large and high powered
– Low power
„ Laser pointers, laser printers, and compact disc players
„ 780 nm aluminum gallium arsenide (AlGaAs) laser diode used in
CD players is most common type of laser
– Large industrial diode lasers can generate great amounts of
heat
„ Used for cutting and welding

LASER

„ The greater the power of the laser,

the greater the potential damage.

Laser Classification by Safety

(cont.)
Power
Class (mW) Visible Safety Concerns
I <0.5 Either* None
II <1 Visible Safe for momentary
viewing;
IIIa <5 Either Photochemical effect
IIIb <500 Either Photobiomodulation,
no photothermal effect,
no harm to skin or clothing,
potential damage to eye
IV>500 Either Photothermal effect,
harmful to skin, eyes, and
*Either, both visible and nonvisible.
clothing, use with extreme
caution

66
 LASER

„ When laser comes in contact with the

skin, it can interact in four different
ways.
„ Absorbed (law of Grothus-Draper)
„ Reflected
„ Scattered
„ Transmitted
„ Only the light that is absorbed has a
biological effect on tissues.

LASER

„ Laser can be delivered in the

continuous or pulsed modes.
„ The pulsed mode allows for the tissue
to cool between pulses, reducing the
spread of thermal damage.
„ Tissue healing <20pps
„ Pain >20pps

Laser effects:
PHOTOBIOMODULATION

„ The act of modifying biological

processes with light. That’s exactly
what laser does—it stimulates tissue in
a way that modifies pain and/or the
healing processes.

67
Effects
„ Wavelength specific
– Type of tissue
– Molecules in the tissue
– Depth of target tissue
– Skin tone
„ Some absorb light, thus less penetrates to
target tissue

Effects

„ Enhanced fibroblast
proliferation
„ Conversion of
fibroblasts to
myofibroblasts
„ Enhanced energy
production within
the cell during
repair
„ Decreased pain

Treatment Parameters

„ Delivery technique
„ Dosage and duration
„ Tissue penetration

„ Note: The parameters of laser pulse rate, duration

and simultaneous wavelengths are currently being
researched to determine the most effective modes of
stimulation for specific tissue types.

68
Treatment Parameters:
Delivery
„ Probe type
– Single
„ Original
– Cluster
„ Gaining popularity
„ Best for treating large areas

Delivery technique

„ Treatment sites include: wounds,

lesions, area of pain, nerve roots and
trunks, trigger points, (acupressure
points) lymphatic and blood vessels

Delivery technique cont.

„ For optimum delivery of laser light, the
probe should be in contact with the skin
(to minimize divergence and reflection).
„ For trigger and acupressure points the
laser can be applied with more pressure
for a massage effect.
„ For treating open wounds, hold the
probe <1cm away without touching the
wound.

69
 Delivery technique

„ For treating large areas:

– Use a cluster probe
– Or scanning method
– Or grid application

Treatment Parameters:
Dosage and Duration
„ Depend on three factors
– Average output power
– Time of light exposure
– Treatment area

Treatment Parameters:
Dosage and Duration
(cont.)
„ Dosage = (Average power 㽢 Tx time) 㾂 Tx
area
– Dosage (J/cm2)
– Average power = average machine output (mW)
– Tx time = length of treatment (min)
– Tx area = area of laser beam or area to be treated
(cm2)
„ Because power output is fixed, formula becomes
„ Tx time = (Dosage 㽢 Tx area) 㾂 Power
– Use table to get desired dosage.

70
Dosage

„ For example: lasing continuously over

a wound site for 15 seconds with a
laser whose output is 1 mW per
second would be 15 mW.

Tissue penetration

„ Laser is ineffective if it does not reach

the target tissues with appropriate
doses.
„ In most cases it penetrates up to 5mm
„ Secondary effects up to 2 cm
„ Function of wavelength

Treatment Parameters:
Tissue Penetration (cont.)
„ Skin color
– Penetration less in darker-skinned patients
„ More light absorbed in cutaneous layers
„ Obesity
– Decreases effects because light has to
travel farther to get to target tissue

71
LASER wavelength

„ The body’s response to laser

application is specific to the laser’s
wavelength. A laser of one specific
wavelength will cause a certain tissue
reaction, whereas a laser of another
wavelength will cause a different
reaction or none at all.

wavelength
„ Therapeutic theory is that specific
wavelengths of laser light, when
absorbed, cause specific physiological
responses in the body.
„ The wavelength (frequency) determines
the color of the laser light.

wavelength

„ Wavelength measured in nanometers.

„ One nanometer = 0.000001 mm

„ Penetration depth increases with

increasing wavelengths

72
Wavelength

„ In the USA, therapeutic lasers have a

wavelength of 650-1200nm. The low
and medium power output associated
with LLLT does not cause significant
thermal changes in the tissues, so
therapeutical benefits are thought to
related to the photochemical effects.

Wavelength/Frequency

„ Wavelength and frequency are

inversely related to each other.
– As the frequency increases, the
wavelength decreases
– As the frequency decreases, the
wavelength increases

Dose

„ Factor of energy (J/cm2) x seconds.

„ Range of .5 to 10.0J/cm2
„ Acute conditions (< .5J/cm2)
„ Chronic conditions (< 3.0J/cm2)
„ Consult with the owners manual for
desired dose for various conditions

73
 Law of Photobiology:
Arndt Schultz Principle
„ Biological reactions are not only dictated
by dose, but the rate at which the energy
is delivered

<500 Hz >500 Hz
Stimulatory Inhibitory

Treatment Parameters:
Dosage and Duration
„ Depend on three factors
– Average output power
– Time of light exposure
– Treatment area

Treatment Parameters:
Dosage and Duration
(cont.)
„ Dosage = (Average power 㽢 Tx time) 㾂 Tx
area
– Dosage (J/cm2)
– Average power = average machine output (mW)
– Tx time = length of treatment (min)
– Tx area = area of laser beam or area to be treated
(cm2)
„ Because power output is fixed, formula becomes
„ Tx time = (Dosage 㽢 Tx area) 㾂 Power
– Use table to get desired dosage.

74
Approximate Laser Dosages
Condition Dosage
Superficial wounds 0.5–4.0 J/cm2
Trigger points 8 J/cm2
Nerve root 8–24 J/cm2
Tendinitis 1–3 J/point
Capsulitis 1 J/point
Epicondylitis 2–3 J/point
Muscle strain 1–2 J/point
Patellofemoral 1–2 J/point
Ligament strain 2–4 J/point
Plantar fasciitis 1–3 J/point

Treatment Parameters:
Tissue Penetration
„ Major issue with light therapy
– Clinically effective only if light reaches target tissue
with appropriate dosage
„ Penetration is function of wavelength and
power
– Wavelength is probably the most important factor.
– But there must be a driving force.

Indications
„ Pain (possibly due to slowing nerve conduction, and release of
endogenous opiates)
„ Acute musculoskeletal trauma (Enwemeka, 2004)
„ Myofascial pain (Simunovic, 1996; 1998)
„ Rheumatoid arthritis (Brosseau, 2000)

„ Carpal tunnel syndrome (Naeser, 2002)

„ Low back pain (Basford, 1999)

„ Trigger points (Simunovic, 1996; 1998)

„ Neck pain (Chow, 2005)

„ Muscle spasm (Iibuldu, 2004)

„ Inflammation (Bjordal, 2006)

75
 Indications
„ Tissue Healing (possibly due to phagocytic
activity)
„ Enhances wound contraction (Hopkins, 2004)

„ Skin ulcerations (Chromey, 1992)

„ Peripheral nerve regeneration (Gigo-Benato, 2005)

„ Flatten and soften keloids (Karu, 1995)

„ Healing of rat incisions (Surinchak, 1983)

Contraindications

1. Irradiation directly into the eye

2. Irradiation of uterus during pregnancy
3. Cancer patients
4. Organ transplant patients

The greater the power of the laser, the greater the

potential damage

Contraindications

„ When used properly, laser is relatively

safe. While many electrical modalities
have extended lists of
contraindications and precautions,
light therapy (laser) appears to be safe
for patients who have pins, metal
plates, plastic implants, growth plates,
and pacemakers, and for treating the
gonads.

76
Precautions

1. Be cautious when applying to patients who

a. Are photosensitive
b. Suffer from epilepsy
c. Have had a recent steroid injection
d. Are taking anti-inflammatory medication
e. Have an acute infection
f. Suffer from a thyroid condition

„ Abstract Objective: Effectiveness of splinting,

ultrasound (US), and low-level laser (LLLT) in the
management of CTS.
„ Materials and Methods: 100 hands of 50 women
patients with bilateral CTS at 3 months post treatment.
„ Three groups,
1. Splinting only,
2. Splinting + US
3. Splinting + LLLT.
Patients were assessed with the Boston Questionnaire,
patient satisfaction inquiry, VAS for pain, and
electroneuromyography.

Results and Conclusion:

• Combinations of US or LLLT with splinting were more
effective than splinting alone in treating CTS.
• However, LLLT + splinting was more advantageous
than US + splinting,
• especially for the outcomes of lessening of symptom
severity, pain alleviation, and increased patient
satisfaction.

77
 Laser as an Adjunctive
Therapy
• Heat therapies (US, Hot Packs)
– Use phototherapy before, increased blood flow causes increased
absorption of light by hemoglobin resulting in decreased penetration
• Phono / Iontophoresis
– Use before steroid or anti-inflammatory agents, this modality
negates the cellular effects of phototherapy, and should be done
before
• Exercise/Mobilization
– May do before or after, depending on the specific goals of
phototherapy
• Cryotherapy (Ice)
– Use phototherapy after due to vasoconstriction, it increases
penetration

Laser Therapy Overview

„ “Treatment with laser therapy is not based on

heat development, but on photochemical and
photobiological effects in cells and tissues .”
-Tuner & Hode, 2010, pg. 71-The New Laser Therapy Handbook

„ “…more than 95% of the laser therapy described

in the literature is performed with lasers in the
<100mW range.”
-Tuner & Hode, 2010, pg. 549

Reimbursement for light

therapy?

„ Code: 97026
„ The therapist uses infrared light as a
form of superficial heat that will
increase circulation to one or more
localized areas. Once applied, and
safety instructions have been provided
to the patient, the treatment is
supervised.

78
 Reimbursement for light
therapy?

„ Code: 97028
„ The therapist applies ultraviolet light
to treat dermatological problems.
Once applied, and safety instructions
have been provided, the treatment is
supervised.

Questions

Enhancing Therapeutic Outcomes With Deep Heating

Modalities: Ultrasound. Dr. David O. Draper, EdD,
ATC,FNATA, - Brigham Young University, Provo, UT

79
 I HAVE A PASSION FOR
ULTRASOUND!

A warm up quiz to get the

brain going

1. Which of the following would

respond best to a 3 Mhz ultrasound
treatment?

„ A) subacromial bursitis
„ B) lateral epicondylitis
„ C) soleus strain
„ D) piriformis syndrome

80
2. Which of the following would
respond best to a 1Mhz ultrasound
treatment?

„ A) medial epicondylitis
„ B) long head of the biceps tentinitis
„ C) patellar tendinitis
„ D) quad strain

3. Which ultrasound frequency

heats the fastest?

„ A) 1Mhz
„ B) 2Mhz
„ C) 3Mhz
„ D) 90 Khz

4. Which structure heats the

fastest?

„ A) tendon
„ B) ligament
„ C) muscle
„ D) fat

81
5. What is the appropriate
treatment size for thermal
ultrasound? ______ times the size
of the soundhead

„ A) 2
„ B) 4
„ C) 6
„ D) 8
„ E) none of the above

6. Ultrasound is most effective

when moved at a speed of what
distance per second?

„ A) 4 cm
„ B) 6 cm
„ C) 8 cm
„ D) 10 cm
„ E) speed of sound head movement is
not a factor with ultrasound

7. The acronym “ERA” refers to:

„ A) the type of tissue being treated

„ B) percent of the crystal that is
transmitting the beam
„ C) the duty cycle
„ D) the energy produced by the crystal
„ E) two of the above

82
8. Driving medication into the
tissues via ultrasound is known as:

„ A) attenuation
„ B) iontophoresis
„ C) phonophoresis
„ D) none of the above

9. Which of the following are

contraindications for ultrasound use?

„ A) sprains
„ B strains
„ C) over implanted metal
„ D) cardiac pacemaker
„ E) two of the above

10. Raising the muscle temperature to

40㼻C is required for what
condition(s)?

„ A) phagocytosis
„ B) pain relief
„ C) acute tendinitis
„ D) muscle spasm relaxation
„ E) stretching

83
11. A measure of ultrasound
energy is called a joule.
„ True
„ False

12. An ultrasound treatment

can be applied for over an
hour.
„ True
„ False

13. An effective ultrasound

treatment should deliver at
least 2000 joules.

„ True
„ False

84
14. Ultrasound can be effective
in the tissue for up to the size
of a baseball.

„ True
„ False

15. Ultrasound machines are

big and bulky.

„ True
„ False

History of Ultrasound

„ Prior to WWII, German scientists were

experimenting with sonar in submarines.
Sound was emitted from the vessel to
detect objects in the surrounding water. The
scientists noticed that fish were destroyed in
the process. Thus the idea of ultrasound
producing biological effects was born.

85
 Ultrasound
• Inaudible, acoustic vibrations of high frequency that may
produce thermal and/or non-thermal physiologic effects
• Form of Acoustic Energy (Sound Waves)

Ultrasound Frequencies

Therapeutic ultrasound:

„ Inaudible, acoustic vibrations of high

frequency that produce thermal and or
nonthermal physiologic effects. (Knight &
Draper, Therapeutic Modalities: The Art and
Science)

86
 Therapeutic Ultrasound
„ Advantage over other non-acoustic heating
modalities
„ Tissues high in collagen (tendons, muscles,
ligaments, joint capsules meniscus, and
cortical bone) can be heated to a
therapeutic range
– Without causing a significant temperature
increase in fat and skin

Anatomy of an Ultrasound
Machine
„ Generator

„ Transducer
– Converts electrical energy
into acoustic energy
– Houses the crystal

„ Crystal

Ultrasound Anatomy
„ Crystal „ Crystal is mounted to the
inside of the transducer
„ Quartz no longer head
used
„ Synthetic
– Barium titanate
– Lead zirconate titanate
„ Produce more uniform
beam and cost less
than quartz

87
 How does ultrasound
work?
„ Crystal in the
transducer converts
electrical energy to
sound energy
– Reverse piezoelectric
effect

How does ultrasound

work?
„ Generator produces a
high frequency
alternating current at 1 to
3 million cycles per
second (MHz).
„ Current travels through
the coaxial cable to the
transducer
„ Transducer converts
mechanical vibration by a
reversal of the
piezoelectric effect

Reverse Piezoelectric
effect
„ Contracting and expanding of a crystal
when an alternating current is passed
through it

88
Compressions and
Rarefactions
„ Compressions
– Areas of high molecular density
– Produced when the crystal expands

„ Rarefactions
– Areas of low molecular density
– Produced when the crystal contracts

In simple terms:

„ Ultrasound is absorbed by tissue

„ Causes molecules to rotate and
bounce off one another
„ Resulting in heat or non-thermal
effects

Law of Grotthus-Draper
„ More energy that is
absorbed by the
superficial tissues, the
ƒ Penetrates through
less that remains to tissues high in water
be transmitted to content
underlying tissues. ƒ Absorbed in tissues
high in protein
– Ultrasound:
ƒ Refracted at joints
ƒ Reflects or bounces off
bone

89
Attenuation
„ Decrease in
energy as
ultrasound passes
through various
tissue layers
– Occurs from
absorption of
sound energy in
the tissues
– Scattering of the
beam

Ultrasound: Quality Control

„ Effective Radiating Area (ERA).

– Portion of the transducer which actually
produces the sound wave
– Measured by scanning the transducer at a
distance of 5 mm & recording all areas that
produce more than 5% of maximum power
output
„ Should be as close as possible to the size of
the transducer䇻s faceplate

Ultrasound: Quality Control

(cont.)

90
Ultrasound: Quality Control
(cont.)

Ultrasound: Quality Control

„ Beam Non-uniformity Ratio

– Amount of variability of intensity within the
ultrasound beam.
„ Should be as close as possible as 1:1
– Most manufacturers use < 6:1
– 8.5 W/cm2 damages tissue

Beam Non-uniformity Ratio

„ a) Good BNR b) Poor BNR

91
 Ultrasound Parameters
• Duty factor „ Treatment Length
• Pulsed or
continuous „ Treatment Size
• Frequency
• 1 to 3 MHz „ Application
• Intensity technique
• Power
• Total Watts
• Treatment
• Watts/cm2

Procedures
„ Under sterile
conditions, a
temperature probe is
inserted into muscle
tissue. The
temperature probe is
then connected to a
computer that can
measure temperature
changes every 1 sec.
„ Ultrasound is then
applied on the skin
over the target tissue.

Continuous Ultrasound

92
Pulsed Ultrasound

Duty Cycle

Frequency
„ Number of times per
second that the crystal
changes shape
„ Determines depth
of treatment
– 3MHz: Surface to
2.5 cm
– 1MHz: 2.5 to 5 cm

93
Frequency
„ Number of times per
second that the crystal
changes shape
„ Determines the rate
of heating
– 3MHz: 3 times
faster than 1MHz

Power & Intensity

„ Power: The total amount of ultrasound

energy produced by the generator.
– Measured in watts.

Intensity: Strength of the soundwaves

-Measured in watts per cm2 (W/cm2)

Intensity
„ Higher the intensity faster the rate of
heating
„ Don䇻t use pre-set intensities when
doing thermal ultrasound.
„ Always abide by patient tolerance
– Patient should feel gentle warmth

94
 Treatment Length

„ Dependent upon:
– Goals
– Size of area to be treated
– Intensity used
– Frequency (MHz)

Dose according to goals

THERMAL CLINICAL TEMPERATURE

EFFECT APPLICATION INCREASE

Mild SUBACUTE INFLAMMATION 10 C

Moderate CHRONIC INFLAMMAITON 20C

MUSCLE SPASM RELAXATION
PAIN MODULATION

Vigorous STRETCH COLLAGEN 40C

INCREASE BLOOD FLOW

Treatment Length*
(based upon treating an area twice the size of the
soundhead)
„ US Rate of Heating per Minute (Human Muscle)
Intensity (W/cm2)1 MHz 3 MHz
0.5 0.04㼻C 0.3㼻C
1.0 0.2㼻C
0.6㼻C
1.5 0.3㼻C
0.9㼻C
2.0 0.4㼻C
1.2㼻C

*Applies only to Omnisound products

95
Size of Treatment Area
„ Should be limited to an area no more
than twice the size of the soundhead

Size of Treatment Area

„ If you treat too large of an area,

Ultrasound won’t heat the tissues

Transducer Movement
„ Use slow strokes
covering about 4
cm per sec.
– Can use either
back and forth or
circular strokes,
being careful to
keep the faceplate
flat on the surface
being treated

96
 Application technique

„ Ultrasound requires a medium or

couplant to be placed between the
soundhead and the skin so that air
does not interfere with transmission of
ultrasound

Coupling Medium
„ Used to eliminate air and
transmit the sound
„ Gel: most common
„ Water: immersion
technique over boney
prominences
„ Gel pads: over boney
prominences
„ Other

Ultrasound Gel Shots

„ Developed by Rich Mar
in 2013

„ Researched by BYU in
2013-2014

97
 Water immersion technique

„ Used to treat small areas when

soundhead cannot lie flat of the tissue
surface (i.e. boney prominences)

Water immersion technique

„ Soundhead does not touch tissue, but is

held 0.5 cm away from and perpendicular to
the target tissues.
„ May need to increase intensity by as much
as 50%

Ultrasound:
What research has revealed about
various ultrasound machines?

Not all ultrasound

machines are
created equal
. Merrick
. Holcomb
. Gulick
. Draper et al.

98
 All ultrasound units are
not created equal Merrick, et al.,
2003

(3MHz for 6 mins at 1.5 W/cm2) 1.6cms depth

All ultrasound units are

not created equal Holcomb, et
al., 2001

„ Omnisound 3000C „ Forte 400 Combo

(Accelerated Care Plus) (Chattanooga, Inc.,)
– 3 Mhz – 3 Mhz
– 10 mins at 1 W/cm2 – 10 mins at 1 W/cm2
– 1.2 cms depth – 1.2 cms depth
– 5.8㼻C increase – 3.8㼻C increase

All ultrasound units are

not created equal: Gulick, 2000.
„ Used a Tektronix oscilloscope to
measure output intensity of four
ultrasound units
– (3 trials each)
„ 1) Intelect 225P
„ 2) Mettler Sonicator 706
„ 3) Rich Mar Model V
„ 4) Omnisound 3000C

99
 Key ultrasound
parameters
„ Frequency
„ Intensity & Duration
„ Effective radiating area of the crystal
(ERA)
„ Beam non-uniformity ratio (BNR)
„ Machine (Is it an 8 cylinder 4x4 or a 4
cylinder rust bucket?)

Results of output intensity:

Gulick, 2000

„ Desired output setting (1.5W/cm2)

„ Average measured intensity------------------------Æ

„ Intelect 225P 1.95*

„ Mettler Sonicator 706 3.63*

„ Rich-Mar Model V 1.03*

„ Omnisound 3000C 1.58

„ * significant at p< .01

100
Thermal Physiologic
Effects:
„ Increased extensibility of collagen fibers
„ Reduced viscosity of fluid elements in
tissues
„ Decreased joint stiffness
„ Reduced muscle spasm
„ Diminished pain perception
„ Increased metabolism
„ Increased blood flow

Thermal Effects

• Duration determined by
1) Desired tissue temperature increase
2) Frequency
3) Intensity (Patient Comfort)
4) Duty cycle of US – Continuous

Nonthermal Physiologic
Effects:
„ Wound healing
„ Vascular regeneration
„ Increased phagocytic reaction of
macrophages
„ Increased protein synthesis
„ Tissue regeneration
„ Cell membrane alteration
„ Increased capillary density of ischemic
tissue

101
 „ Remember, that thermal ultrasound
also delivers the mechanical effects.

Wound Healing Etc

„ Ultrasound parameters: 3MHz at 20% duty cycle .5-
1W/cm2.
„ Can be applied over hydrogel dressing.
„ Keep clean.
„ Theory: US and electrical stimulation, excites tissues to
create granulation (growth) and healing.

Indications
„ Soft tissue healing &
repair
„ Resolving pitting edema
„ Scar tissue/joint

„
contracture
Heat & stretch routine GO
„ Chronic inflammation
„ Bone healing?
„ Assessing stress
fractures
„ Pain
„ Effects of deep heat

102
Contraindications
„ Thermal ultrasound when TTR is not wanted
„ Areas of lost sensation
„ Areas of decreased circulation
„ Vascular problems such as thrombophlitis
„ Over eyes, reproductive organs, during
menstruation
„ Pacemaker
„ Malignant tissue
„ Active infection
„ Epiphyseal plates (precaution)

Thermal Effects

„ Those of heat „ Altered nerve

„ Increase in conduction velocity
extensibility of „ Increased
collagen fibers metabolism
„ Decrease in muscle „ Increased blood
stiffness flow
„ Reduction of „ Diminished pain
muscle spasm perception

Myths

„ Metal
„ Total knee because of gel
„ Spine
„ Menthol containing lotions, gels

103
Guidelines for Use
„ Obtain history
„ Determine goal
„ Position patient
(comfortably)
„ Inspect treatment area
„ Obtain appropriate size
sound-head
„ Determine frequency
„ Set duty cycle
„ Apply couplant
„ Set treatment time
„ Maintain contact
„ Adjust intensity to
perception of heat
„ Terminate treatment
„ Assess efficacy
„ Record treatment
response and
parameters

Other uses of ultrasound

„ Phonophoresis: aka sonoporation:
„ Ultrasound to increase cell membrane
permeability, facilitating delivery of
medication molecules to precise
locations of the body

Phonophoresis
„ Common medications used in
phonophoresis:
– Anti-inflammatories:
„ Cortisol, salicylates, dexamethasone
- Analgesics:
- Lidocaine

104
 Combination therapy
„ By using a dispersive electrode, ultrasound head
works as the active electrode.
– In this setup the athletic trainer can cause the gluteals and
piriformis muscle to contract for treating piriformis
syndrome

Heat & Stretch

„ Heat the area prior to:

– or during stretching
– Joint mobilizations
– Friction massage

Stretching Window
„ Time period (window of
opportunity) of vigorous
heating when stressed
tissues undergo their
greatest extensibility and
elongation

„ Tissue heated to 40㼻C

will drop to 38㼻C within
5–10 min after an
ultrasound treatment has
terminated

105
Joint mobilization cases with ultrasound
as the deep heating modality

„ I enclose a few of my favorites

Avascular necrosis in a 21 yr old

collegiate soccer player (goalie)

„ Freshman yr in college (Oct. 01), while trying

to stop a goal, ball smacked the dorsal aspect
of his wrist.
„ Scaphoid fx not suspected (not typical MOI)
„ X-rays did not reveal a fracture to the
scaphoid.
„ Was in a wrist splint for 2 weeks.
„ Continued to play with moderate pain.

Avascular necrosis in a 21 yr old

collegiate soccer player (goalie)

„ Scaphoid fx not suspected (not typical MOI)

106
 Avascular necrosis in a 21 yr old
collegiate soccer player (goalie)

„ At end of his Freshman yr he went on a 2 yr

religious mission in Mexico.
„ During this time his wrist continued to hurt.
„ Medical help was not sought in Mexico.
„ Did not play soccer.

Avascular necrosis in a 21 yr old

collegiate soccer player (goalie)

„ When he returned to BYU at the end of his 2

yr religious mission to Mexico he still
complained of pain in his wrist.
„ On x-ray and other examinations it was
determined that he had avascular necrosis of
the scaphoid.

Avascular necrosis in a 21 yr old

collegiate soccer player (goalie)

„ A bone graft from his thumb was used to

surgically repair the non-union (Nov. 04).
„ His wrist was placed in a cast for 12 weeks.
„ When the cast was removed he went through
a few weeks of passive stretching.
„ Full flexion was reached, but he could only
extend the wrist 50㼻. The Physician said,
䇾Don䇻t expect to gain anymore ROM.䇿

107
 Avascular necrosis in a
21 yr old collegiate
soccer player (goalie)

„ March 11, 05. Referred to our Lab.

„ Treatment regimen included:
– Ultrasound, 3MHz at 1 to 1.5 W/cm2
„ Continuous mode
„ 2 x size of soundhead faceplate
„ 6 to 8 mins
„ Ventral and Dorsal side of wrist

The beginning ROM was 50㼻 extension prior

to the first treatment and 62㼻 extension at
the end of the first treatment

„ [the opposite wrist extended to 85㼻]

Non-thermal or Mechanical
Effects
„ Increased histamine „ Cell membrane
release alteration
„ Calcium ion influx „ Attraction of immune
„ Increased phagocytic cells to injured area
activity of „ Increase in fibroblasts
macrophages „ Vascular regeneration
„ Increased protein „ Tissue regeneration
synthesis
„ Wound healing
„ Increased capillary
density of ischemic
tissue

108
After just 3 treatments (every other day) the
athlete gained 20㼻of wrist extension
(beginning ROM 50㼻 extension; ending ROM
70㼻 extension

„ Before After

(Frozen wrist) of a 22 year old

male.
„ When he was 19, a surgeon
accidentally severed 3 extensor
tendons in his hand while trying to
extract a ganglion cyst.

„ Another surgeon repaired the

tendons.

„ Extensive physical therapy was

performed (ultrasound and passive
stretch).

(Frozen wrist) of a
22 year old male.
(Lacking ROM for 3
years)

„ Reported to BYU Therapeutic Modality

Research Lab (April. 2003)

„ Flexion was 49㼻 (80-90㼻 is normal)

„ Extension was 65㼻 (normal is 70-

80㼻)

109
 (Frozen wrist) of a 22
year old male. (Lacking
ROM for 3 years)

Treatment regimen consisted of continuous

ultrasound (3MHz; 1.5W/cm2; ERA 2; 4 mins
each side). {Recent research has shown that
this will heat tissue to over 40㼻C}.

Immediately after the ultrasound, joint

mobilizations were performed for 6-8 mins.

Ultrasound treatment

(Frozen wrist) of a 22 year old

male. (Lacking ROM for 3 years)

110
 (Frozen wrist) of a 22
year old male.
(Lacking ROM for 3
years)
Subject gained 15㼻 of
wrist extension with just
3 treatments of PSWD
and joint mobilizations.
(Returned to normal)

before

after

(Frozen wrist) of a 22
year old male. (Lacking
ROM for 3 years)

Subject gained 23㼻 of

wrist flexion with just 3
treatments of PSWD and
joint mobilizations.
(lacked about 8㼻 of
normal)

before

after

This patient had surgery to repair 3 extensor tendons.

Three years later he still lacked full ROM. He
underwent a regimen of 3MHz ultrasound followed by
joint mobilizations.

„ Wrist flexion prior to 3 „ Wrist flexion after 3 treatments

treatments

111
 Example (Duration)

„ If you run at a pace of 8 min/mile you

exert little work or energy in 1 mile.
However if you run a pace of 8
min/mile for 10 miles, you exert 10
times more work or energy.

Avascular necrosis in a 21 yr old

collegiate soccer player (goalie)
Ventral glides of the scaphoid, lunate and
triquetrium were performed on the radius for
6-8 mins. Also traction of the carpals on the
radius and ulna were performed.

Early indications show that using thermal

ultrasound prior to stretching or joint
mobilizations increases the range of motion of a
joint.

112
Reimbursement for Ultrasound

Long Duration Low

Intensity Therapeutic
Ultrasound:
Is this the future?

David O. Draper
Justin H. Rigby
Brigham Young University

What is LDLI ultrasound?

„ Long duration
– up to 4 hours

„ Low intensity
– 0.132 W/cm2

„ Duty Cycle
– 100%

113
It is possible to deliver these long
duration low Intensity treatments
because the device is:
„ Portable
„ Small (about the size of a TENS unit
„ Battery-Operated
„ Self-administered
„ Comfortable
„ Worn during the course of daily life

ZetrOZ – Long Duration Low Intensity

Therapeutic Ultrasound Device

Indicated for:
„ Relief of Pain

„ Relief of Muscle Spasms

„ Local Increase in Circulation

ZetrOZ Clinical Study on Knee

Osteoarthritis – Results

Preliminaryȱversionȱ
ofȱtheȱZetrOZȱDeviceȱ
inȱkneeȱosteoarthritisȱ
study

114
 ZetrOZ Clinical Study on Tendinitis –
Results

Preliminaryȱversionȱ
ofȱtheȱZetrOZȱDeviceȱ
inȱshoulderȱtendinitisȱ
study

ZetrOZ Clinical Study on Muscle Spasm –

Results Part 1
Preliminaryȱversionȱofȱ
theȱZetrOZȱDeviceȱinȱ
muscleȱspasmȱstudy

ZetrOZ Temperature
Study
„ N=12 (7 males, 5
females, age=23.0㼼1.9)
„ Inserted temperature
probes at 1.5 and 3.0 cm
– Verified with imaging US
„ Delivered ultrasound with
1 or 2 ultrasound
applicators for 3 hours
– Crossover design
„ Measured 30 minute
temperature decay

115
ZetrOZ Temperature Study -
Results

ZetrOZ Temperature Study -

Results

„ LDLI ultrasound delivers up to 18,720

Joules per treatment because it is
applied for up to 4 hours.

116
 Will LDLI ultrasound replace
traditional ultrasound? (no)
„ This is like trying to
compare apples to
oranges

Traditional „ A typical therapeutic

Ultrasound
ultrasound treatment:
„ Lasts from 5-15 minutes
„ Requires constant
monitoring by a clinician
„ Can reach therapeutic
level in 5-10 min.
„ 1-3 Mhz
„ .1 – 2.5 W/cm 2
„ Pulsed or continuous
mode

LDLI „ Low intensity

ultrasound (0.132W/cm2)
„ Long duration (2-4
hours)
„ Static application
„ Little monitoring by a
clinician
„ Takes 30+ min to reach
therapeutic level
„ 3Mhz
„ Continuous mode

117
 Ultrasound Benefits Traditional Wearable Solution
• Reduced pain •Large size and cost • Wearable
• Reduced •Not portable • No Mess
inflammation •Treatment time 5-15 • Use Daily
• Increased healing mins • Long Lasting
rate •Applied by clinician • Battery Powered
• Non-invasive •Messy gel

• Simple treatment

Think or LDLI ultrasound as

another tool for clinicians to
use

„ There are several studies

Joule: A measure of that claim ultrasound
work or energy
does not work. As we
have examined these
studies we noted that
the wrong parameters
were used. For example
the treatment area was
too large, the treatment
time too short or the
intensity was too low to
reach the desired effects

118
 Ultrasound works Ultrasound doesn’t

Draper; 1993-2010 Robertson; 2001

„ Johns; 2002 Jewell; 2009
„ Ramierz;
„ Saini; 2002
„ Crisci; 2002 Why ultrasound
„ Takakura; 2002 works
Alexander; 2010!!!

„ The articles that support

Joule: A measure of
work or energy
the use of ultrasound
used the appropriate
joules to reach the
treatment goals.

Numerous studies have demonstrated

that ultrasound is most effective when
providing greater than 2000 Joules of
energy per treatment. Higher energy
deposited strongly correlates with
results.
Rx
Frequency SATA Energy/
Study Injury time
(MHz) (W/cm2) RX
(min)
Downing & Supraspinatus 4,076 –
1 1.0 – 2.0 15.8
Weinstein (1986) tendinitis 8,152

Calcific
Ebenbichler et al
0.89 tendinitis 0.5 15 2,250
(1999)

Shomoto et al Calcific
3 1.2 6 4,320
(2002) tendinitis
Köybaúi et al (2010) 1 Hip OA 1.0 15 4,500

119
 Billing for Ultrasound

„ CPT Billing Code: 97035

„ Application of a modality to one or more areas;
ultrasound each 15 minutes
– The provider utilizes ultrasound to increase circulation in
one or more areas. A coupling agent (such as gel or
water) must be used to facilitate the procedure. The
delivery of corticosteriod medication is called
phonophoresis and is reported using this code.

Evidence-Based Medicine
„ We are
getting
closer

US

„ Max treatments = ~20

„ The End!

120
1. Which of the following would
respond best to a 3 Mhz ultrasound
treatment?

„ A) subacromial bursitis
„ B) lateral epicondylitis
„ C) soleus strain
„ D) piriformis syndrome

2. Which of the following would

respond best to a 1Mhz ultrasound
treatment?

„ A) medial epicondylitis
„ B) long head of the biceps tendinitis
„ C) patellar tendinitis
„ D) deep quad strain

3. Which ultrasound frequency

heats the fastest?

„ A) 1Mhz
„ B) 2Mhz
„ C) 3Mhz
„ D) 90 Khz

121
4. Which structure heats the
fastest?

„ A) tendon
„ B) ligament
„ C) muscle
„ D) fat

5. What is the appropriate

treatment size for thermal
ultrasound? ______ times the size
of the soundhead

„ A) 2
„ B) 4
„ C) 6
„ D) 8
„ E) none of the above

6. Ultrasound is most effective

when moved at a speed of what
distance per second?

„ A) 4 cm
„ B) 6 cm
„ C) 8 cm
„ D) 10 cm
„ E) speed of sound head movement is
not a factor with ultrasound

122
7. The acronym “ERA” refers to:

„ A) the type of tissue being treated

„ B) percent of the crystal that is
transmitting the beam
„ C) the duty cycle
„ D) the energy produced by the crystal
„ E) two of the above

8. Driving medication into the

tissues via ultrasound is known as:

„ A) attenuation
„ B) iontophoresis
„ C) phonophoresis
„ D) none of the above

9. Which of the following are

contraindications for ultrasound use?

„ A) sprains
„ B) strains
„ C) over implanted metal
„ D) cardiac pacemaker
„ E) two of the above

123
10. Raising the muscle temperature to
40㼻C is required for what
condition(s)?

„ A) phagocytosis
„ B) pain relief
„ C) acute tendinitis
„ D) muscle spasm relaxation
„ E) stretching

11. A measure of ultrasound

energy is called a joule.

„ True
„ False

12. An ultrasound treatment

can be applied for over an
hour.
„ True
„ False

124
 13. An effective ultrasound
treatment should deliver at
least 2000 joules.

„ True
„ False

14. Ultrasound can be effective

in the tissue for up to the size
of a baseball.

„ True
„ False

15. Ultrasound machines are

big and bulky.

„ True
„ False

125
126
 

Bibliography

Speaker Name: David Draper,EdD, ATC

Title: Proven Modalities that Pay for Themselves: Electrotherapy, Laser, and Ultrasound

Articles

Draper DO, Maloy L, Johnson W, Eggett D, Rigby JH. Single-use electrodes are as effective as
multiple-use electrodes for producing sensory, motor threshold amplitudes and force production.
Athletic Training & Sports Health Care; 5(3) 2013, pp 123-128.

Draper DO, Wells A, Rigby JH. The Omnisound 3000C in the delta T mode is valid at producing
predicted temperature increases. Athletic Training & Sports Health Care; 5(2) 2013, pp 77-80.

Draper DO, Knight KL, Rigby JH. High-Volt Pulsed Current: Treatment of Skin Wounds and
Musculoskeletal Injuries.
International Journal of Athletic Therapy & Training; 17(4), 2012.

Coglianese M, Draper DO. @% Lidocaine with epinephrine is absorbed in tissues 5mm below
the skin’s surface. Journal of Athletic Training. 46(3), 2011, 270-276.

Draper DO, Castel JC, Coglianese M, Shurtz J, Mack G: The use of microdialysis in determining
the delivery of iontophoresis driven lidocaine into the human gastrocnemius muscle. Journal of
Athletic Training. 46(3) 2011,277-281

Draper DO. The effect of ultrasound and joint mobilization on wrist ROM on post operation
wrists: A case series. Journal of Athletic Train. 2010, 44:486-491

Draper DO, Edvalson CG, Knight KL, Eggett, DL. Temperature Increase in the Human Achilles
Tendon During Ultrasound Treatments Comparing Commercially made Ultrasound Gel, Full-
thickness and Half-thickness Gel Pad Mediums, J Althl Train, 2010;45(4)333-337.

Draper DO, MaHaffey C, Eggett D. Therapeutic ultrasound softens trigger points in upper
trapezius muscles. Physiotherapy Theory and Practice. 2010; 26(3), 167-172.

Draper DO. Superficial and Deep Heat. Journal of the Japanese Physical Therapy Association.
36(8)Dec 2009

Draper DO. Commentary to: Intramuscular temperature differences between the mid-point and
peripheral effective radiating area with ultrasound. J SPORTS SCI &MED, Sept. 2008

Draper DO. Ultrasound works and compliments therapy. Physical Therapy Journal Online.2007;
87(8)986-989.

Draper DO, Knight KL. Interferrential Current Therapy: Often Used but Misunderstood. Athletic
Therapy Today. 2006; 11(4) 29-31.

127
 

Oates D, Draper DO. Retoring wrist range of motion using ultrasound and mobilization: A case
study. Athletic Therapy Today. 2006; 11(1), 57-59.

Anderson MA, Eggett D, Draper DO. Combining topical analgesics and ultrasound, Part 2.
Athletic Therapy Today. 2005; 10(2), 45-47.

Draper DO, Anderson M. Combining topical analgesics and ultrasound, Part 1. Athletic Therapy
Today. 2005; 10(1)26,27.

Draper DO, Anderson M. Best of Both Worlds:Flex-All“ combined with ultrasound gel can
enhance therapeutic ultrasound outcomes. Advance for Directors of Rehabilitation. Nov. 2004 .

Knight KL, Draper DO. Critical Thinking and Therapeutic Modalities. Athletic Therapy Today.
2004; November: 28-29.

Gallo JA, Draper DO, Thein-Body L, Fellingham GW. A Comparison of Human Muscle
Temperature Increases During 3-MHz Continuous and Pulsed Ultrasound With Eequivalent
Temporal Average Intensities. Journal of Orthopaedic and Sports Physical Therapy.
2004;34(7)395-401.

Bishop S, Draper DO, Knight KL, Feland JB, Eggett D. Human tissue temperature rise during
ultrasound treatments with the Aquaflex® gel pad. J Athl Train. 2004:39(2) 126-139.

Draper DO. A winning combination: When used together, ultrasound and joint mobilization are a
powerful pair for improving range of motion. Rehab Management. Nov. 2003, 18-21. [editorial
review]

Draper DO. Facts First: Contrary to recent reports, Ultrasound is an effective modality: Part I.
Advance for Directors of Rehabilitation. 2002, February:75-87. [editorial review]

Draper DO. Get the Facts: Ultrasound is more than a placebo: Part II. Advance for Directors of
Rehabilitation. 2002, March: 67-70. [editorial review]

Darrow H, Schulthies SS, Draper DO, Ricard MD, Measom GJ. Serum dexamethasone levels
after decadron phonophoresis. J Athl Train. 1999;34(4) 338-341

Draper DO, Abergel PR, Castel JC. Rate of temperature change in human fat during external
ultrasound: Implications for liposuction. American Journal of Cosmetic Surgery. 1998; 15 (4)
361-367.

Draper DO. Guidelines to enhance therapeutic ultrasound treatment outcomes. Ath Therapy
Today, 1998;3:(6) 7-11.

Stay JC, Ricard MD, Schulthies SS, Durrant E, Draper DO. Pulsed ultrasound fails to diminish
delayed onset muscle soreness symptoms whether delivered once or twice daily. J Athl Train.
1998;33(4):341-346.

Draper DO, Harris ST, Schulthies SS, Ricard MD, Knight KK, Durrant E. Hotpack and 1 MHz
ultrasound treatments have an additive effect on muscle temperature increase. J Athl Train.
1998;33:321-324.

128
 

Ashton D, Draper DO, Myrer JW, Durrant E. Temperature rise in human muscle during
ultrasound treatments utilizing flex-all as a a coupling agent. J Athl Train. 1998;33:136-140.

Draper DO, Anderson C, Schulthies SS, Ricard MD. Immediate and residual changes in
dorsiflexion range of motion using an ultrasound heat and stretch routine. J Ath Train,
1998;33:141-144.

Chan AK, Myrer JW, Measom G, Draper DO. Temperature changes in human patellar tendon in
response to therapeutic ultrasound. J Ath Train, 1998;33:130-135.

Butterfield DL, Draper DO, Ricard MD, Myrer JW, Durrant E, Schulthies SS. The effects of
high volt pulsed current electrical stimulation on delayed onset muscle soreness. J Athl Train,
1997;32:15-20.

Rose S, Draper DO, Schulthies SS, Durrant E. The stretching window part two: Rate of thermal
decay in deep muscle following 1 MHZ ultrasound. J Athl Train, 1996;31:139-143.

Draper DO. Ten mistakes commonly made with ultrasound use: Current research sheds light on
myths. Athletic Training: Sports Health Care Perspectives. 1996;2:95-107.

Draper DO, Ricard, MD. Rate of temperature decay following 3MHz ultrasound: the stretching
window revealed. J Athl Train, 1995;30:304-307.

Draper DO, Castel JC, Castel D. Rate of temperature increase in human muscle during 1 MHZ
and 3 MHZ continuous ultrasound. J Orthop Sports Phys Ther. 1995;22:142-150.

Draper DO, Schulthies S, Sorvisto P, Hautala A. Temperature changes in deep muscles of

humans during ice and ultrasound therapies: An in-vivo study. J Orthop Sports Phys Ther,
1995;21:153-157.

Draper DO, Sunderland S, Kirkendall DT, Ricard M. A comparison of temperature rise in the
human calf muscles following applications of underwater and topical gel ultrasound. J Orthop
Sports Phys Ther. 1993;17:247-251.

Draper DO, Sunderland S. Examination of the law of Grotthus-Draper: Does ultrasound

penetrate subcutaneous fat in humans? J Athl Train. 1993;28:246-250.

Texts

Knight KL, Draper DO. Therapeutic Modalities: The Art and Science. 2nd ed. Wolters
Kluwer/Lippincott Williams & Wilkins, Baltimore, MD. 2013, 473 pages

Cameron MH. Physical Agents in Rehabilitation: From Research to Practice. 2nd ed. Saundars,
Phiadelphis, PA. 2003, 491 pages

Michlovitz SL, Bellew JW, Nolan TP. Modalities for Therapeutic Intervention. 5th ed. F.A. Davis,
Philadelphia, PA. 2012, 459 pages

Starkey C. Therapeutic Modalities. 4th ed. F.A. Davis, Philadelphia, PA. 2013, 429 pages

129
 

Denegar CR, Saliba E, Saliba S. Therapeutic Modalities For Musculoskeletal Injuries. 3rd ed.
Human Kinetics, Champaign, IL. 2010, 290 pages

130
Cross Country Education complies with all rules and regulations set forth by the
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Instructions for Completing your Scan Evaluation Form

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2. DO NOT bend or fold your Scan Evaluation Form.
3. Please make solid marks that fill the response completely without any stray
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4. Complete your first and last name in ALL CAPS (if you do not have enough
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8. Clearly mark all boxes appropriately.
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10. Return your completed Scan Evaluation form back to the instructor.
 Seminar Evaluation Objectives

Proven Modalities that Pay for Themselves

Speaker: Dr. David Draper, Ed.D., ATC

The purpose/goal of this activity is to guide participants through the most effective
therapeutic uses of each modality; demonstrating how, why, and when to implement each
type of therapy through highly engaging labs and case study discussions.

Objectives:

1. Explain how electrotherapy, laser, and ultrasound work?

2. Identify specific dysfunctions that respond strongly to electrotherapy, laser, and ultrasound?

3. Discuss up-to-date indications, contraindications, and myths related to these modalities?

4. Examine new, state-of-the-art therapeutic applications?

5. Recognize the most common mistakes clinicians make when using these modalities?

6. Discover what the thermal and non-thermal effects of ultrasound are, and how to obtain
them?

7. Determine how to use these modalities with special populations such as teenagers and
pulmonary sensitive patients?

8. Document the use of these modalities to aid reimbursement?

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 PROVEN MODALITIES THAT PAY FOR THEMSELVES – ON-DEMAND
Presented by Dr. David Draper, EdD, ATC

TEST - 2

1. Which theory about pain by Melzack and Wall proposes a mechanism, located in the dorsal horn of the
spinal cord, which allows only one sensation at a time to pass through to the brain?
a. central control
b. gate control
c. endogenous opiate
d. pattern

2. In what part of the body is the pain gate located?

a. cerebral cortex
b. brainstem
c. ventral horn
d. substantia gelatinosa

3. The body's naturally occurring painkillers are referred to as ________.

a. endogenous opiates
b. T cells
c. nociceptors
d. dopamines

4. Which of the following is a contraindication for ultrasound?

a. pain
b. skin anesthesia
c. muscle spasm
d. heat before stretching

5. Monopolar stimulation involves the use of active and dispersive electrodes. The parameter that determines
which pad(s) will be active is the _________.
a. polarity adjustment
b. average current
c. pulse duration
d. current density

6. During NEMS, the A electrode is 10 a 5 in, and electrode B 7 X 7 in. This type of stimulation would be
classified as____.
a. monopolar
b. bipolar
c. quadripolar
d. polypolar

1
7. The amount of energy required to produce a muscle contraction is ______.
a. <10 mA
b. 11-20 mA
c. >30 mA
d. 1-15 µA

8. The most common AC wave form is _____.

a. square
b. triangular
c. sine
d. rectangular

9. To form a closed circuit in the body’s tissues, at least one electrode from each of the generator's output
leads must_____.
a. touch the skin
b. be larger than the other electrode
c. be saturated in water
d. be smaller than the other electrode

10. What happens when the number of twitch contractions per second rises?
a. improved lymphatic drainage
b. relaxation
c. tetany
d. pain reduction

11. Two equal-size electrodes are placed in the target treatment area and an equal amount of stimulation is
felt under each electrode. This is known as ______.
a. bipolar placement
b. monopolar placement
c. quadripolar placement
d. dual-polar placement

12. The large electrode that is used with a unipolar technique is called
a. alternating
b. an ampere
c. the circuit
d. dispersive

13. Any alteration in the magnitude or any variation in the duration of an electrical current is called ____.
a. frequency
b. modulation
c. ohm
d. adaptation

14. A unit of measure that indicates the rate at which electrical current is flowing is the _____.
a. volt
b. ampere
c. ohm
d. watt

2
15. Which type of modality uses medium frequency as its carrier frequency?
a. TENS
b. MENS
c. iontophoresis
d. IFC

16. Which type of modality uses a direct current?

a. TENS
MENS
b. iontophoresis
c. IFC
d. both b and c

17. Which type of modality uses a low-frequency alternating current?

a. TENS
b. MENS
c. iontophoresis
d. IFC

18. Which on-off cycle would be the best for the prevention of atrophy during the early phases of rehabilitation
using Russian stimulation?
a. 10/10
b. 20/20
c. 10/30
d. 10/50

19. Which on-off cycle would be the best for reducing a muscle spasm using NMES?
a. 10/10
b. 20/20
c. 30/10
d. 10/30

20. Which of the following modalities is primarily used to modulate pain?

a. TENS
b. MENS
c. IFC
d. a and c

21. Which of the following would be the best crystal BNR?

a. 3:1
b. 1:3
c. 4:1
d. 1:4

22. When reading your ultrasound manual, it says that during the pulsed mode, your unit has a 1:5 duty
cycle. This means that the current is ______.
a. off 80% of the time
b. off 75% of the date
c. on 30% of the time
d. on 20% or the time
3
23. Which of the following is the least effective ultrasound couplant?
a. water
b. ultrasound gel
c. massage lotion
d. petroleum jelly

24. The abbreviation W refers to the _______.

a. power or intensity of the treatment
b. pulse duration (width)
c. number of pulses per second
d. type of current (alternating or direct)

25. The decrease of energy contained within a sound wave as it travels through tissue is known as
_________.
a. the Ardnt-Schultz principle
b. the law of Grotthus-Draper
c. attenuation
d. the piezoelectric effect

26. Which of the following is the best tool for a massage therapist to use to treat trigger points?
a. Ultrasound
b. TENS
c. IFC
d. Russian Stim

27. Which of the following can a physical therapist use to reduce pain according to the gate control
theory?
a. Ultrasound
b. TENS
c. IFC
d. Russian Stim

28. Which of the following can an occupation therapist use to decrease pain over a large area such as
the low back?
a. Ultrasound
b. TENS
c. Russian Stim
d. IFC

29. Which of the following was invented by Yakov Kotts?

a. Ultrasound
b. TENS
c. IFC
d. Russian Stim

4
30. Which of the following uses an electrical current to deliver medicine under the skin?
a. Iontophoresis
b. IFC
c. TENS
d. All of the above

31. Which modality was invented about the same time as the gate control pain theropy?
a. TENS
b. IFC
c. Russian Stim
d. Iontophoresis

32. Which of the following falls under the umbrella of NMES?

a. TENS
b. IFC
c. Russian Stim
d. Iontophoresis

33. Which modality delivers heat deep in the bodies tissues?

a. TENS
b. IFC
c. Russian Stim
d. Ultrasound

34. Which ultrasound frequency goes deepest in the tissue?

a. 1MHz
b. 2MHz
c. 3MHz
d. None of the above

35. Pulse width is also called:

a. Pulse phase
b. Pulse current
c. Pulse duration
d. Pulse train

36. The ideal treatment ratio for muscle re-education using Russian Stimulation is 10 sec on/10 sec off.
a. True
b. False

37. The ideal treatment ratio for decreasing edema using Russian Stimulation is 10 sec on/10 sec off.
a. True
b. False

38. The “L” in the acronym LASER stands for light.

a. True
b. False
5
39. A contraindication for laser is pain.
a. True
b. False

40. An indication for laser is wound healing.

a. True
b. False

41. 3MHz ultrasound is ideal for tennis elbow.

a. True
b. False

42. 1MHz ultrasound is ideal for patellar tendinitis.

a. True
b. False

43. The treatment size for ultrasound is 4 times the size of the soundhead.
a. True
b. False

44. 3MHz ultrasound heats about 3 times faster than 1MHz ultrasound.
a. True
b. False

45. When using ultrasound, a tendon will heat faster than a muscle.
a. True
b. False

46. An ultrasound treatment duration can last for more than 2 hours.
a. True
b. False

47. An ultrasound device can be as small as a TENS unit.

a. True
b. False

48. The Zetroz or SAM ultrasound device can use up to 3 crystals.

a. True
b. False

6
49. Ultrasound is contraindicated over metal implants.
a. True
b. False

50. An effective ultrasound treatment should deliver at least 2000 joules.

a. True
b. False