SonicStim Combined Ultrasound and TENS

Contents• Introduction to Sonic Stim

• What are the benefits of a combination unit?

• Principles of Ultrasound – Trigger points– Conventional therapy

Introduction to Sonic Stim• 3 products in 1

– Ultrasound therapy unit and TENS machine combined into a single, ergonomic device for home and ambulatory treatment. Mains operated.

• Ultrasound therapy– One preset programme can be used separately for pain therapy,

for the typical applications of 1 MHz ultrasound (deep tissue treatment of muscle pain).

• Combined therapy– 7 combined ultrasound and TENS programmes. The ultrasound

head is used as one of the TENS electrodes. This combined therapy dramatically amplifies the effects of both treatments.

• TENS therapy– Treatment for general pain relief, featuring 7 preset TENS

programmes.

Benefits of Combination Unit• Pain Relief during Therapy

– When Ultrasound therapy is used, the patient will probably be presenting with pain. Simultaneous use of TENS provides pain relief and reassurance during therapy

• Improved compliance– Patient may not always feel much during Ultrasound therapy.– TENS reinforces patient confidence and encourages them to

cooperate in completing the course of Ultrasound treatments.

What Is Ultrasound Therapy?Ultrasound (US) is a form of MECHANICAL energy, • Particles of a material, when exposed to a sound wave will oscillate

about a fixed point rather than move with the wave itself. • As the energy within the sound wave is passed to the material, it will

cause oscillation of the particles of that material

Ultrasound has two principle effects: • Cell membrane becomes ‘excited’ thus increasing the activity levels

of the whole cell. The US energy acts as a trigger for this process, but it is the increased cellular activity which is in effect responsible for the therapeutic benefits

• Micromassage. Sound wave travelling through the medium is believed to cause molecules to vibrate, enhancing tissue fluid interchange & affecting tissue mobility.

Principles of Ultrasound - Frequency• Depth of penetration

– Ultrasound loses energy as it penetrates the tissue.– Higher frequency loses energy faster– 1MHz loses 50%at 4cm depth

– The best absorbing tissues in terms of clinical practice are those with high collagen content – LIGAMENT, TENDON, FASCIA, JOINT CAPSULE, SCAR TISSUE

1 MHz 3 MHz

4 cm

Principles of Ultrasound – Power Control• The energy delivered is controlled by pulsing the output.

• Pulse lasts 2ms, and power is controlled by varying the on/off time ratio

• SonicStim has settings of 5/20/50/80/100%

20%50%

Principles of Ultrasound – Using Gel• The Ultrasound wave is reflected at tissue density boundaries (that’s

how U/S imaging works)

• The greater the difference in material density at a boundary, the greater the reflection that will occur, and therefore, the smaller the amount of energy that will be transferred.

• Coupling gel is required when using therapeutic ultrasound (US) to maximize acoustic contact between the transducer and the tissue.

• SonicStim shuts off to protect the vibrating crystal from damage when there is an air gap

• The gel harbours germs. It’s important to clean the head with alcohol between patients

What Are Trigger Points?The SonicStim manual concentrates mainly on Trigger Points

• Trigger points cause pain more often than any other condition, are drastically under-diagnosed due to lack of information.

• Trigger points are specific, hyperirritable and hypersensitive areas in muscle that suffer from decreased circulation, increased contraction and spasm.

• Lack of circulation creates a high anomaly of toxins and increased nerve sensitivity that can range from low ache to sharp pain.

• Now just because the trigger point causes the pain does not mean that the spot is painful itself. When the pain causing spot is painful it is called a primary trigger point. However, pain can also manifest itself in areas away from the active trigger point - such pain is called referred pain.

Trigger Points - Referred Pain• The most common referred pain is in the form of headaches and

shoulder pain, caused from trigger points in the back of the neck (occipital ridge area, levator scapulae), shoulder (upper trapezius) and upper back (rotator cuff, rhomboids and lower trapezius).

• Upper Trapezius Trigger Point (TP1) Upper Trapezius Trigger Point (TP2), Mid Trapezius Trigger Point (TP3)

• Such trigger points can remain dormant for very long periods of time but will eventually cause spasm or pain. A great many headaches are caused from these trigger points referring sensation into certain areas of the head (typically the myofascial muscle area); the headache symptoms usually are treated with painkillers, though the underlying cause is almost never addressed!

Trigger Points - Referred Pain

Trigger Points - Referred Pain

Trigger Points - Referred Pain

Causes Of Trigger Point Pain• Tender trigger points typically develop from lack of stretching or

improper stretching but can also be caused from stress/trauma, repetitive motion or even poor posture.

• Other common causes are:

• Reduced circulation in trigger points will eventually lead to muscle shortening and restricted movement which further accentuates the pain, thus completing a cycle of decreased mobility and further pain. This commonly becomes the underlying cause of chronic headache pain, and the patient will continue to suffer from these until the problem trigger points are treated directly.

sitting without firm back support (slumped posture) prolonged sitting in a chair without armrests, or armrests that are too high, or too low (leaning to one side)

cradling a phone between ear and shoulder large breasts

one leg shorter than the other typing on a keyboard that is too high

prolonged improper sleeping position overly tight bra straps

carrying a purse (prolonged hiking up of the shoulder) head-forward posture

whiplash walking with a cane that is too long

Common Symptoms of Trigger Point PainCommon symptoms of trigger point pain residing in the

trapezius and shoulder/neck muscles are:

– headaches on the temple (tension headaches) – pain behind the eye – dizziness or vertigo – severe and/or sharp neck pain – stiff neck (limited range of motion) – intolerance to weight on the shoulders (purse, backpack, etc.) – pain on the back of the shoulder pain or on the inside of the

upper arm – a deep ache over the top of the shoulder – a burning pain close to the spine between upper shoulder blades

The Physiology of a Trigger Point• The part of a muscle fibre that actually does the contracting is a microscopic unit called a sarcomere. Contraction

occurs in a sarcomere when its two parts come together and interlock like fingers.• Millions of sarcomeres have to contract in your muscles to make even the smallest movement. A trigger point

exists when over-stimulated sarcomeres are chemically prevented from releasing from their interlocked state.

A Microscopic View

• The drawing is a representation of several muscle fibers within a trigger point. It’s based on a microscopic photograph of an actual trigger point. This particular trigger point would cause a headache over your left eye and sometimes at the very top of your head.

– Letter A is a muscle fiber in a normal resting state, neither stretched nor contracted. The distance between the short crossways lines (Z bands) within the fiber defines the length of the individual sarcomeres. The sarcomeres run lengthwise in the fiber, perpendicular to the Z bands.

– Letter B is a knot in a muscle fiber consisting of a mass of sarcomeres in the state of maximum continuous contraction that characterizes a trigger point. The bulbous appearance of the contraction knot indicates how that segment of the muscle fiber has drawn up and become shorter and wider. The Z bands have been drawn much closer together.

– Letter C is the part of the muscle fiber that extends from the contraction knot to the muscle’s attachment (to the breastbone in this case). Note the greater distance between the Z bands, which displays how the muscle fiber is being stretched by tension within the contraction knot. These overstretched segments of muscle fiber are what cause shortness and tightness in a muscle.

• Normally, when a muscle is working, its sarcomeres act like tiny pumps, contracting and relaxing to circulate blood through the capillaries that supply their metabolic needs. When sarcomeres in a trigger point hold their contraction, blood flow essentially stops in the immediate area.

• The resulting oxygen starvation and accumulation of the waste products of metabolism irritates the trigger point. The trigger point responds to this emergency by sending out pain signals.

Treatment of Trigger Points

• When Therapeutic Ultrasound is applied over these trigger points, the ultrasonic vibration gently massages the area, bringing in blood flow (flushing lactic acid and toxins) and gently massaging the tensed muscle tissue, creating a term known by doctors as "trigger point release".

• Once a sensitive trigger point is released, the referred pain quickly subsides and once all sensitive trigger points are released, your headache / neckache / back pain is gone!

• Luckily, the pain and other symptoms caused by trigger points occur in predictable patterns. When you know where to look, trigger points are easily located and deactivated with simple techniques of self-applied massage.

• With trigger point treatment, myofascial pain can usually be eliminated within three to ten days. Even long-standing chronic conditions can be significantly improved in as little as six weeks.

Conventional Ultrasound Therapy

• Ultrasound therapy is often used to assist tissue healing after wounds and injuries.

• The treatment settings used need to be varied with depth of injury site and the stage of healing

Ultrasound Therapy - Tissue Repair• The application of ultrasound during the inflammatory,

proliferative and repair phases is of value not because it changes the normal sequence of events, but because it has the capacity to enhance these normal events and thus increase the efficiency of the repair phases

• if a tissue is repairing in a compromised or inhibited fashion, the application of therapeutic ultrasound at an appropriate dose will enhance this activity.

• If the tissue is healing ‘normally’, the application will, speed the process and thus enable the tissue to reach its endpoint faster than would otherwise be the case.

• The effective application of ultrasound to achieve these aims is dose dependent.

Ultrasound Therapy – Inflammatory Phase• During the inflammatory phase, US has a stimulating effect on the

mast cells, platelets, white cells with phagocytic roles and the macrophages

• For example, the application of ultrasound induces the degranulation of mast cells, causing the release of arachidonic acid which itself is a precursor for the synthesis of prostaglandins and leukotreine – which act as inflammatory mediators

• By increasing the activity of these cells, the overall influence of therapeutic US is certainly pro-inflammatory rather than anti- inflammatory. The benefit of this mode of action is not to ‘increase’ the inflammatory response as such but rather to act as an ‘inflammatory opimiser’

• The inflammatory response is essential to the effective repair of tissue, and the more efficiently the process can complete, the more effectively the tissue can progress to the next phase (proliferation).

• Cntd.• US is effective at promoting the normality of the inflammatory

events, and as such has a therapeutic value in promoting the overall repair events .A further benefit is that the inflammatory chemically mediated events are associated with stimulation of the next (proliferative) phase, and hence the promotion of the inflammatory phase also acts as a promoter of the proliferative phase.

• US makes as efficient as possible to earliest repair phase, and thus have a promotional effect on the whole healing cascade.

• For tissues in which there is an inflammatory reaction, but in which there is no ‘repair’ to be achieved, the benefit of ultrasound is to promote the normal resolution of the inflammatory events, and hence resolve the ‘problem’

• This will be most effectively achieved in the tissues that preferentially absorb ultrasound – i.e. the dense collagenous tissues.

Ultrasound Therapy – Inflammatory Phase

Ultrasound Therapy – Proliferation Phase• During the proliferative phase (scar production) US also has a

stimulative effect though the primary active targets are now the fibroblasts, endothelial cells and myofibroblasts

• These are all cells that are normally active during scar production and US is therefore pro-proliferative in the same way that it is pro- inflammatory – it does not change the normal proliferative phase, but maximises its efficiency – producing the required scar tissue in an optimal fashion.

• low dose pulsed ultrasound increases protein synthesis and several research groups have demonstrated enhanced fibroplasia and collagen synthesis

Ultrasound Therapy – Remodelling Phase• During the remodelling phase of repair, the generic scar that is

produced in the initial stages is refined such that it adopts functional characteristics of the tissue that it is repairing. A scar in ligament will not ‘become’ ligament, but will behave more like a ligamentous tissue. This is achieved by a number of processes, but mainly related to the orientation of the collagen fibres in the developing scar and also to the change in collagen type, from predominantly Type III collagen to a more dominant Type I collagen. The remodelling process is certainly not a short duration phase – research has shown that it can last for a year or more – yet it is an essential component of quality repair

• The application of therapeutic ultrasound can influence the remodelling of the scar tissue in that it appears to be capable of enhancing the appropriate orientation of the newly formed collagen fibres and also to the collagen profile change from mainly Type III to a more dominant Type I construction, thus increasing tensile strength and enhancing scar mobility.

• Ultrasound applied to tissues enhances the functional capacity of the scar tissues.

Principles of Ultrasound – Dose calculationRequired dose can be calculated from the following

Depth >1cm Intensity Acute 0.1-0.3 W/cm2 at required depth

SubAcute 0.2-0.5Chronic 0.3-0.8

Treatment: Duration: 1 minute for each multiple of treatment head area to be covered, daily

SonicStim Power at 100% Depth cm W/cm2

at 100%Acute Sub

AcuteChronic

Duty Cycle

0.5 0.9 5-20 20-50 20-80

1 0.8 5-20 20-50 20-100

2 0.7 20-50 20-50 50-100

3 0.6 20-50 50-80 50-100

4 0.55 20-50 50-100 50-100

5 0.50 20-50 50-100 50-100

6 0.4 20-80 50-100 80-100

WARNINGS FOR USE• Never use the ultrasound unit without using the conductive ultrasound gel. • Never clean the unit with water or submerge it under water. • Never use the Ultrasound device on children under the age of 16 without the

recommendation/supervision of a physician or therapist. • Never use Ultrasound device over the scalp, temple, eyes or thyroid area (Grey on the diagram).

Use no longer than 2 minutes on a specific area of the masseter muscle (highlighted in green on the diagram on the right). On the back of the neck, trapezius muscle and side neck muscles below the skull, treat for no longer than 10 minutes, 3 times daily.

The use of Ultrasound device is NOT recommended:

• Over the pelvis, abdomen and lumbar (lower back) region in pregnant or potentially pregnant females.

• Over highly ultrasound-sensitive organs (eyes, ears, ovaries, testicles, brain, spinal cord) • On patients with pace-makers • On patients with phlebitis, deep venous thromboses • On patients with haemophilia• On patients with spina bifida or surgical laminectomies of the spine • On tissue and/or bone with active infection • Over areas suspected to be cancerous or pre-cancerous or previously treated with deep X-ray• Over de-sensitized (numb, hypoaesthesia) areas of the skin (eg. diabetic neuropathy) • Over open sores or lesions • In the front of the upper neck (thyroid region)• We recommend you consult a physician before using any medical device.

Contraindications• This device should not be used:-

– for symptomatic local pain relief unless etiology is established or unless a pain syndrome has been diagnosed.

– when cancerous lesions are present in the treatment area.– when open wounds are present in the treatment area.– on patients suspected of carrying serious infectious disease and

or disease where it is advisable, for general medical purposes, to suppress heat or fevers.

– over or near bone growth centers until bone growth is complete.– over the thoracic area if the patient is using a cardiac

pacemaker.– over a healing fracture.– over or applied to the eye.– over a pregnant uterus.– on ischemic tissues in individuals with vascular disease where

the blood supply would be unable to follow the increase in metabolic demand and tissue necrosis might result.

Additional Precautions• Additional precaution should be used when the

ultrasound is used on patients with the following conditions:– Over an area of the spinal cord following a

laminectomy, i.e., when major covering tissues have been removed.

– Over anesthetic areas.– On patients with hemorrhagic diatheses.

Potential for Burns• It is possible for ultrasound therapy to cause burns if the therapy is

not performed properly. Skin burns can result from one or more of the following:

• Using a stationary technique (holding the sound head in one place).• Moving the sound head too slowly.• Treating an area with sensory nerve damage (or the loss of normal

skin sensations).• Desensitized areas can be overheated or burned without the

patient’s knowledge. Use extreme caution with these patients (e.g., diabetes, neural damage, etc.).

• Bony prominences are especially vulnerable: they reflect sound waves and increase intensity to the periosteum

• Patients with an implanted neurostimulation device must not be treated with or be in close proximity to any ultrasound. Energy from ultrasound can be transferred through the implanted neurostimulation system, can cause tissue damage and can result in severe injury or death.