Laser: - a dose dependent modality - Monochrome: production of light in 1 specific wavelength - Collimated: directed in direction - Coherent: all photons

are the same Production of laser light: - pumping- energy source causes atoms to move rock to excited state - Photon hits atom and jumps up valency - spontaneous emission- as an atom returns to the norm uninterrupted - this causes emission of one photon in any direction - Any not parallel to direction of emission are attenuated Stimulated Emission - striking of an incident photon into an excited atom - same proton= cloned - 1 in- 2 out Amplification: - Proton bounces back and forth increasing the interaction - some escape semi-reflective mirror and create laser Physiological Effects - interacts with organic molecules of various types - Chromophores are the molecule that are getting interacted with by the - Photobiomodulation- either stimulation or inhibition based on dose mW: units range from 1-300mw Wavelength: do not vary within a uni, but from differing units - longer the wavelength- the greater the penetration and the wider range of the molecules it may influence Tip Size: Not variable within a uni - .25 to .3 mm - difference between single diode and cluster types Time: moves @ a constant rate of 1 sec/ sec Healing Properties/Effects: = metabolic processes = mRna synthesis and cell devision = collagen and connective tissue production = in fibroblast activity- proliferation and pro-collagen = lymphatic system removal of bacteria - Immunological: - phagocytosis - Bacterial Effect on E.Coli - Stimulation of T and B Lymphocytes activity

- Inflammation: - Cell change in wall permeability - antioxidant production of Super Oxide Dimutase; which inhibits prostaglandin formation .2 -.3 J/cm2

Indications:
-Burns -Wounds: non healing, post surgical ulcerations -Connective tissue injury - TRP - Oedemas *Overall it IMPROVES RATE AND QUALITY OF TISSUE HEALING

Contraindications:
- over or near neoplastic lesions - during first trimester of pregnancy - Directly over open wounds- unless a barrier is used (ie. Gladwrap) - Directly over unstable DVT Cautions: - retinal damage

HOW TO USE: - Time= .2/.005 x .25 or 2/.005x.25 Time=10 seconds or 100 seconds 1. Calculate desired amount of energy 2. Choose High Setting 3. Draw Squares on/ around the area 4. Push Button
- Youre achieving your J/cm2 (.2jcm2- inflammatory) in 10 seconds per cm2 on patient - .005 is the watts for the device (set) for HIGH - .0025 is the watts for the device when set for LOW (DONT USE)

Ultrasound: An acoustic modality - produced by reversed piezoelectric effect: movement created in a crystal caused by application of an electrical current - applying an alternating current results in expansions and contractions producing sound waves Effects on Tissues: - sound waves will react differently with different tissues Transmission: - coupling media is used because it transmits the soundwaves well without being greatly affected by them. ie. Gel - less dense a tissue, the more it will transmit the waves Attenuation: - acoustic energy absorbed will cause greatest attenuation - becomes greater if the fx is increased Absorption: - Where therapeutic effect takes place - the more dense a tissue- the greater the absoption, thus the greater the heating effect ultrasound will have on it Reflection: - bone is dense enough to cause significant reflection of the sound waves. This significantly increase the heating effects on the Periosteum and surrounding the soft tissue - metallic implants, pins, plates, cages Thermal Effects: - intensity in the given tissue is great enough to cause heating - only reason to have a heated head: general relaxing- warms up connective tissue= for chronic problems- ie. Scar tissue Non- Thermal Effects: - everything else, often ignored or underplayed Chemical: - vibrations help to stimulate rates of chemical activity - kinetic energy is converted to thermal thus increasing the excitement of the chemicals Biological: - the cell membrane permeability is altered - this allows for enhanced cell function and exchanged - secondary hypoxia- amount of stuff from inflammation but not removed. NO 02- all cells around them suffer also.

Mechanical: - the movement of molecules will have a variety or effects, some of which are: - oscillation of particles in fluid - decrease in viscosity - loosening cell and molecule structure Acoustic Streaming: - due to the unidirectional movement that ultrasound produces - Causes movement, most marked at the edge of cells - may help in cell metabolism - acoustic streaming causing modulating effect

Indications:
- Acute and Chronic inflammatory conditions (tendonitis, bursitis, capsulitis) - Trp- trigger point- dont like pain - no mechanical Calcific Deposits: tendinosus- later stages - worried about stiffness want to break down deposits - cause a little inflammation - Healing soft tissue injuries - healing Fractures - both these are managed by the use of Low Intensity Pulsed Ultrasound Contraindications: - Infection- inviting new blood - Vascular Disorders- deep vein thrombosis - Patients on blood thinning medication - Use over heating creams- deep heat Phonophorisis: - Using ultrasound, topical agents may be driven deeper into tissue - topical agents, Difflam, voltarin Non-thermal: pushing inflammation out - sound wave through tissue moves molecules e.g. think flour and sieve - be aware of metallic implants, pins, plates and cages

- Gel Patient or put extremity into bucket of water - patient position is very important -Gel Ultrasound head before you touch machine - put meringue on ultrasound head - w/cm2- .5 - duty cycle: 50% or 100% - Time- Duty Cycle- Intensity

- TIME: How long - Small Area: supraspinatus, iliolumbar ligament, ankle and wrist or insertion 50% @ .5wpcm2prevents heat - Large Area: moreso continuous, erector spinae, ITB ACUTE: .5- 1 wcm2 (pulsed- DC 50%)- no heat CHRONIC: .5-1.5wcm2- Heat- Continuous

SCENARIO:

Pt comes in to see you with a Sprained Ankle - Clastic Phase - 1 hour before- rolled ankle - starting to get swollen, tissue damage, not healing yet Controlling and Managing Condition: ACUTE: - Compressive Bandage, Elastic Bandage - not ankle brace, tape (b.c it decreases proprioception) - Cold Pack- (10-20 mins) for 24-48 hours (10 on, 10 off) - Anti Inflammatory- Topical Pharmaceutical- Difflam and Voltaren - Natural- Arnica and Traumeal - Ultrasound- .5w per cm2 DC= 50% SUBACUTE: - Comfrey- pain modulating and wound healing properties- blastic activity-maturation - Laser @ 2J - blastic activity- quality and rate of tissue healing - Prescribe Excercises that lay down bone/tissue in relation to stress - Passive ROM

PERSON WHO HAD NOT DONE THIS. - ultrasound= .5 wcm2 @ 100% Duty Cycle trying to get some heat- break up tissue to lay it down again properly - Heat packs: to increase extensibility and flexibility. Maybe do some effleurage - Soft Tissue= cross Friction= cold ice pack after

Electrical Pain Modulation: - Pain relief may be afforded several different ways using electrical stimulation Sensory, Motor, Noxious- Nociceptor Sensory: activation of large diameter sensory fibres - blocks impulses from other sensory receptors - effects are immediate but not long lasting - very local pain killing- natural release Motion: Stimulating neuro-muscular junction - low intensity causing small contractions may work in a similar manner to sensory - Higher intensities causing larger- stronger contractions may supress the CNS - may also help in decreasing inflammation which will have a role in pain perception. - the effects are longer lasting. Noxious: strongly effecting fibres leads to analgesia

TENS: - Therapeutic Effect: - decrease pain through gaiting or endorphins - Motor function through local effects on nn. - Target Tissues: - sensory, motor nn, nociceptive Pulse Width: (30 (motor rehabilitation) -250 microseconds (sensory and motor)) Intensity: Channel 1 or 2- wait for sense of tingling- then increase until pain is gone Mode: burst, normal, modulated Contraindications: - Cardiac Pace Makers; app safe for fixed rate pacemakers- but not demand - Trans- Thoracic/ Cerebral - Ant Neck- may interefere with breathing and swallowing - Carotid Sinus Area- may have an effect on cardial rhythm - Pregnancy (relative) - Dementia - Lack of Sensation Indications: - Pain Relief - Muscle Re education - Rehab - Oedema Reduction - Obstetric

Interferential: Using 2 currents of medium frequencies (approx.. 400-500 hz) Quad Polar- bonus with interferential- get the burst of the TENS machine- but you dont get the noxious stimuli of the sensory - Has a single carrier frequency- which doesnt do anything - Channel 1: carrier - Channel 2: 4085 *peak of both at same time- summate causing depolarisation - Skin Impedance: - Two Types: - Ohmic: Electrode size, skin condition, amount of hair, hydration level (low effects) - Capacitive: ability to pass a current - Skin acts as a capacitor; storing holding and resisting current flow - is inversely related to frequency - increase fx= easier to pass through body - b/c carrier fx= more comfortable penetrates deeper - claimed to be the great advantage of interferential Effect: the primary physiological effect is depolarisation of peripheral sensory or motor nerves Indications: - Pain- via sensory and motor innervation - muscle re-education -motor - Oedema Management Contraindications: - Cardiac Pace Makers; app safe for fixed rate pacemakers- but not demand - Trans- Thoracic/ Cerebral - Ant Neck- may interefere with breathing and swallowing - Carotid Sinus Area- may have an effect on cardial rhythm - Pregnancy (relative) - Dementia- Not an inhouse- person has to carry it around (therefore TENS better) - Lack of Sensation Cautions: - Patients may become dependent because they like the feel - Symptomatic Approach - Some ptt may have an adverse reaction including- fainting, rash, increase pain Electrode Placement: - Bi-Polar - Just fx we set- mi in machine - QuadPolar

- fx current passes with current - 2 sets of electrodes crossed - fx- beats per second Pre-Mod/ Bipolar: - the current of one or both channels is modulated in the unit - Thus patient receives the thereapeutic frequency only Pros: - can use each channel in a different treatment area - no need to balance amplitude Cons: - due to being modulated in the machine- the fx of the skin receives is lower and thus is stimulated more Quad Polar: - Each channel enters the patient at the carrier frequency - the two, on crossing interact and form the therapeutic beats - treatment area is placed at the crossing point Pros: The fxs are modulated in patient, thus allowing for better penetration, less skin resistant - more comfort for the patient - w-scan: useful for large areas or vague pain Cons: only one treatment area may be addressed * constant and premod- makes a TENS machine Muscle Rehab: - 1-10hz: - Quadpolar - 20-40 mins - Set Ampl. to 0- tell them to notify you when it begins to tingle- turn up until muscle begins to tingle Sensory pain: - 80-150hz - Premodulation - 30 mins - 0- always reset to 0. * BALANCE: change it to whichever end is still hurting more than other. Then Increase Beat fx. Modulation: - interferential- carries fx- 4000 or 5000 hz - relations between fx and resistance= fx= passes through body easier- muscle rehabilitation - you get the benefits of muscle rehabilitation- without the sensory stimuli Therefore more comfortable for the patient. 1 Area: Quad Polar - muscle rehab

Hand Held Massagers: - General Relaxation - Gaiting of pain - Mobilization of fluid - Oedema - Postural Drainage - Post- Exercise - Assisting in breaking up adhesions - fascia, muscles and tendons - Altering muscle tension - TrP - with other STT (PNF, MFR, OI) Indications: - General Relaxation - Hypertonic or Hypotonic mm -mechanism is unknown - Adhesions - Congestion Contraindications: - Acute Inflammation - Malignancy - Infection- includes skin lesions - Vibration intolerant ptt - Vascular Pathology - Hemorrhage - Thrombophlebitis - Varicose vv Treatment Times: - General Relaxation: 3-5 mins - Gaiting of Pain- 3-5 mins - Mobilization of fluid -Oedema with ice (10-12 mins) - Postural drainage (5-15 mins) - Post- Exercise (5-15 mins) - Assist in breaking up adhesions - fascia, muscles, tendons less then 10 mins Altering muscle Tension: - Trp- 6 seconds - STT 10 seconds- 2minutes

Ultrasound:

- Inflammation - .5 wpcm2= 50% Duty Cycle = 20% err on the side of caution - Heating - .5wpcm2= 100% Laser: - Healing Tissue - Centre the squares over area of pathological structures - 2J- blastic activity- increase speed of activity - .2J- inflammation- phagocytosis, change in cell wall permeation Tens: - Handheld/ transportable pain modulating device