With the exception of thermal agents, ultrasound is the most commonly used modality in the management of soft tissue complaints.

Proposed Effects of Therapeutic Ultrasound

 

2. Extracorporeal Shock Wave Therapy

This is a treatment used in some specialist centres for the treatment of chronic soft tissue pain.

 

Several factors affect the efficacy of this therapy:

 

• Type of machine used
• Specific characteristics of the complaint being treated
• Use of diagnostic ultrasound scanning to guide therapy
• Dose of shock waves

For further information select: Extracorporeal Shock Wave Therapy

 

3. Shortwave Diathermy

 

Shortwave diathermy delivers high frequency electromagnetic energy that is absorbed by tissues, resulting in a heating effect. Treatment is delivered in either continuous or pulsed forms, with the former causing greater heating effect. Fat and muscle, having a high water content, are selectively heated at depths of up to 5 cm.

 

SW diathermy is used in deep-seated injuries, including bursitis, muscle injuries and some tendinopathies. Contraindications include local ischaemia, circulatory disturbance, sensory deficit, pregnancy, bleeding disorders, malignancy and sensitive areas.

 

4. Other Electrical Agents

 

A number of different forms of electrical stimulation are in common use in the management of soft tissue complaints.

 

Examples:

(A) Transcutaneous Electrical Nerve Stimulation (TENS).

Electrical stimulation may result in a reduction in pain in a format of low intensity, high pulse frequencies. Transcutaneous Electrical Nerve Stimulation (TENS) is a process that uses an electrical current, applied through surface electrodes applied to the skin, to alter the perception of pain. A variety of approaches to electrode placement have been described but direct placement over or around the painful site is common practice.

 

High frequency (conventional) TENS involves pulses at high frequency and short duration and selectively stimulates A-delta fibres, closing the pain pathway gate to pain. Onset of pain relief occurs within the initial 10 minutes of treatment and may persist for minutes to hours afterwards.

 

Low frequency TENS, involving higher intensity but lower frequency, shorter duration pulses results in pain relief probably as a result of release of β-endorphins from the pituitary. Relief of pain may take longer to occur than with high TENS, but may be longer lasting; however no overall difference in the degree of pain relief between the two types has been demonstrated.

 

Low TENS is best avoided in the acute phase of an injury.

 

A third, and final, form of TENS involves stimulation at high intensity, high pulse frequency and long duration (Brief-Intense TENS). Pain relief is generally of short duration.

 

The use of TENS units for pain control has several advantages. They are safe, non-addictive, easy to use, patient operated and portable. Side effects are possible: they may cause skin irritation and, of course, may not be effective. They should not be used in the patient with a pacemaker or an arrhythmia and must be used with caution in those with epilepsy. The patient should not operate a machine or drive during use. Although there is a theoretical risk of thermal burns, the risk is negligible.

 

INSTRUCTIONS FOR USING YOUR TEN:

 

Initial treatment should be less than 30 minutes and the response (including adverse reactions) then evaluated. Provided you have tolerated the therapy, treatments can subsequently  last up to an hour at a time, with a minimum of 30 minutes break at a time.

 

The intensity is one that produces strong tingling or buzzng under the electrodes, without discomfort.

 

Recommendations for electrode placement include over or close to the painful area, over motor points, over a peripheral nerve supplying the cutaneous area over the site of pain, or over the paraspinal region, over peripheral nerves that supply the dermatome or myotome of the site of pain. Ultimately the choice of the type of electrode placement depends upon the condition involved and patient preference, and at times a degree of trial and error. Unilateral or bilateral placement may be selected, and a minimum distance between electrodes equal to the diameter of the electrode is recommended.. Some units require the use of gel for skin contact and tape to secure the electrodes. A diary of pain levels and machine use is often helpful in evaluating the response.

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(B) Neuromuscular electrical stimulation (NMES)

 

NMES aims to stimulate and re-educate muscle, to limit atrophy, to maintain range of motion and reduce muscle spasm and involves high amplitude, longer pulse duration. It is particularly useful in the early phases after injury/operation and is superior to no exercise at all as it canlead to improved local blood flow and reduced oedema. In the less acute patient it is not a substitute for active rehabilitation. Daily treatments can be given but the response of the patient should be closely monitored.

 

Contraindications include avulsions and muscle-tendon lesions if it is considered that any increase in muscle tension may be detrimental.

 

(C) Interferential Stimulation

Interferential therapy is suggested to include analgesia, neuromuscular stimulation, and reduction of swelling, although as is the case with so many modalities, evidence is lacking.

 

(D) Iontophoresis

Iontophoresis involves the use of low voltage electrical current to deliver medication into the skin or subcutaneous structures. Such medications include anaesthetics, analgesics and NSAIDs. There is no evidence for benefit from this approach.

  

(E) Laser Therapy

The use of Laser (light amplification by stimulated emission of radiation) to cut and destroy tissue is well established. The same electromagnetic radiation, at much lower intensities, can elicit non-destructive physiological responses in tissues in the absence of significant heating (‘cold laser’ therapy).  This phenomenon forms the basis for the use of ‘laser therapy’ in the management of a variety of soft tissue complaints.

 

An assortment of devices exists. The proposed effects of laser therapy are pain relief and tissue healing, with the latter resembling the non-thermal effects proposed for therapeutic ultrasound. Laser energy commonly penetrates tissues at a depth of a few millimetres, although it is possible to stimulate tissues at a depth of up to 15mm below the skin. Pain reduction may also take place through reduction of muscle spasm or altering nerve conduction velocity.  Nevertheless, the clinical utility of laser therapy remains unestablished.