As a manufacturer of rehabilitation equipment, there are few things we find more rewarding than witnessing the positive difference our products can make to people’s lives. This is why the story of Chattanooga’s latest Center of Excellence is so inspiring.
A Chattanooga Center of Excellence (CoE) is a facility recognized for its contribution to the improvement of patient rehabilitation. Recognition can be earned on the basis of clinical practice, educational initiatives or expertise, or clinical research in the fields of sport rehabilitation and orthopaedics, pain management, neurology, or long-term care. All Chattanooga Centers of Excellence have expertise in one or more Chattanooga physical medicine modalities or technologies.
Our latest CoE is Spain’s DACER clinic. Based in Madrid, DACER is a rehabilitation center specializing in the treatment of adults and children with neurological injuries. Using products supplied by DJO Spain, it helps its patients to make what many people might consider to be small steps, but which they experience as massive gains.
The DACER team receiving their Chattanooga Center of Excellence Certificate
One such patient is Lucas de Ulucia. In 2019, Lucas’s professional motorcycle racing career was tragically cut short when an accident left him quadriplegic. Though he was informed by doctors at Spain’s leading neurology clinic that progress was unlikely, Lucas refused to accept their prognosis, and instead turned to DACER for help.
Two years later, thanks to intensive daily training supported by DACER’s dedicated team of professionals and Chattanooga rehab products, Lucas has regained a significant amount of mobility and greatly improved his quality of life.
Lucas de Ulucia
No head injury is too severe to despair of, nor too trivial to ignore.
Quote by Hippocrates, seen on the wall of DACER center
Standing quietly in the background of this story is Xavier Cardona, General Manager of DJO Spain. Xavi’s relationship with DACER goes back more than a decade to when he introduced its clinicians to VitalStim for dysphagia. Since then, the clinic’s portfolio of Chattanooga products and associated expertise has grown to the point that it has achieved the status of Chattanooga Center of Excellence. The center now acts as a key opinion leader in its field, educating physical therapists from around Spain and Latin America, as well as providing a practical training environment for Chattanooga products.
When Xavi visited DACER last month to present them with their certificate, he was met with an award of his own in recognition of the support he has provided them over the years. It’s clear to see the admiration both parties have for one another, as well as the dedication they share for improving the lives of patients through rehabilitation.
And while both awards were gratefully received, it’s safe to say neither are as rewarding for their recipients as the satisfaction of seeing patients like Lucas reclaiming their freedom through movement.
Radial pressure wave (RPW) therapy can be used on a range of anatomical structures, each requiring different application techniques and parameters. These treatments can be combined in a session depending on the pathology and the condition.
Treating trigger points with RPW therapy
RPW therapy can help release trigger points and reduce the associated pain.
Patient position
Place the patient in a relaxed position with the affected muscles slightly stretched. Observe the level of pain experienced and reduce the stretch if necessary.
RPW transmitters
The most commonly used transmitters for trigger point treatment have a diameter of 15 mm or 20 mm, with 20mm myofascial transmitters being the most effective.
Intensity
The application pressure for trigger point treatment varies between 1 and 5 bar, depending on the transmitter size and the patient’s rating of pain intensity, which should not exceed grade 5 to 7 on a Visual Analogue Scale.
Frequency
The therapeutic pulse frequency is 4 to 20 Hz. In general, higher frequencies seem to be more tolerable than low frequencies.
Number of pulses per trigger point
As the objective should be to reduce the patient’s pain by at least half, the number of RPW pulses required depends on the envisaged degree of pain relief. Once the desired pain reduction level has been reached, move on to treat the next trigger point in the same way. Typically the range of shocks will lie between 1,000-2,000.
Number of pulses per session
This depends on the patient’s condition, but the total number of pulses to be applied can reach 6,000 to 10,000 depending on the treatment surface, divided between local treatment and large-area muscle treatment. It is recommended that no more than 6,000 shocks should be applied over a specific point.
Area to be targeted
Treat active trigger points as well as satellite trigger points in the area of referred pain. If trigger points cannot be identified, target painful muscle spots. Bear in mind active myofascial trigger points refer distally and may present as an insertional tendinopathy.
Application technique
Hold the applicator at a right angle to the muscle surface to have the shortest possible distance to the target area. RPW devices with 5 bar of pressure and a good quality 20 mm diameter transmitter have been shown to have a maximal penetration depth of 7.60 mm. Ensure the transmitter stays in close contact with the skin without pressing too hard; firm pressure is only required with inferior handpieces. Treating over bone is not harmful but can cause severe discomfort, so patients should be informed for their consent. Treatment directly over the spine or to the head is contraindicated.
Treating tendons and tendon insertions with RPW therapy
Application techniques
Use small circular movements on the pain points along the tendon both medially and laterally using the stamping technique described below.
Treating muscles with RPW therapy
Two different techniques can be used:
Smoothing
To reduce muscle tone, move the applicator slowly along the skin surface in the direction of the muscle fibre, working from distal to proximal, without exerting pressure, but keeping the transmitter touching the skin via the transmission gel.
Stamping
Using the same treatment parameters and application direction as for muscle smoothing, apply 30 to 50 radial pressure waves to an identified trigger point or painful area at medium contact pressure before moving the applicator by the width of the transmitter head to the next application site. So named because this technique leaves a ‘stamping pattern’ (temporary redness) due to increased blood flow that quickly resolves.
Number of pulses
500 to 6,000 pulses, depending on pain intensity and the size of the muscles and muscle groups. For example, quadriceps, hamstring, gluteal, and calf muscles require 6,000 pulses using a smoothing technique.
Treating fascia with RPW therapy
The fascial system is one continuous structure that exists from head to toe without interruption. A healthy fascia is elastic and can glide along other fascial structures, but if this gliding quality is restricted, so-called adhesions occur in the system. Because of the interconnection of the fascia, the effects of fascial adhesions can spread through the entire kinetic chain. RPW therapy can help release connective tissue adhesions and constrictions.
In myofascial release, the restricted tissues are manipulated to promote normal sliding and gliding movements of muscles and fascia. RPW fascia transmitters deliver pressure waves tangentially into the tissue instead of vertically to optimize the required movement of the tissue layers. Applications with these transmitters are not carried out at a 90° angle as with other RPW transmitters, but at 45° instead.
Please see the user manual of your RPW device for a full list of clinical indications, contraindications, warnings, and precautions.
Laser therapy is a clinically proven effective adjacent treatment modality in the physical therapy practice intended for the relief of painful muscles and joints associated with acute and chronic tissue injuries1. It is also indicated for helping relieve pain and stiffness associated with osteoarthritis through its ability to increase localized blood flow.2
Although Low Level Laser Therapy (LLLT) devices have been used in physical therapy treatments for decades3, their relative low power means treatment times are excessive and impractical when treating larger areas and/or deeper tissues.
However, High Power Laser (HPL) therapy devices are capable of delivering sufficient power (at a level of Watts compared to the mW output of LLLT devices) to achieve therapeutic dosage without prolonging the application time. This allows treatment of a wider range of indications including deep and large structures within reasonable times, making HPL both an effective and practical physical therapy modality.
LightForce Deep Tissue Therapy Lasers
In the field of therapeutic laser technology, LiteCure® has long been one of the market’s leading manufacturers, with its LightForce® range of products used to deliver an estimated 1.2 million treatments per month in 29 countries around the world. Founded in 2006, the company has recently been acquired by DJO®, a leading global provider of medical technologies. By adding LiteCure to its portfolio, DJO plans to further increase the global presence of LightForce products and make their therapeutic value available to even more clinicians and patients.
All three devices share a set of core features which work together to provide users with safe, user-friendly, and controllable functionality, so that no matter which model they choose they can be assured of a positive and effective user experience.
LightForce Therapy Lasers – three different devices to meet your needs
Customers looking to introduce high power laser therapy into their practice have three different LightForce devices to choose from, each with its own maximum level of power, ranging from 15W to 40W.
All three devices share a set of core features which work together to provide users with safe, user-friendly, and controllable functionality, so that no matter which model they choose they can be assured of a positive and effective user experience.
LightForce® XLi Therapy Laser – 40W
Increased power, for the busiest practices treating the most challenging cases.
Capable of delivering up to 40W of power, the LightForce® XLi is the most powerful device in the range. Its increased power reduces the time needed to apply a therapeutic dose of light energy, and with real-time dosing feedback and the XL Treatment Cone, deeper structures can be treated faster over larger areas, all of which helps clinicians to increase the efficiency of their practice.
LightForce® XPi Therapy Laser – 25W
As above, but with a maximum of 25W of power.
LightForce® FXi Therapy Laser – 15W
A portable unit for practices treating in multiple locations in or out of the office.
At 3.2 kg, the LightForce® FXi is easy to transport, with a rechargeable battery that lasts for up to half a day on a single charge, making it the ideal choice when you need to bring the treatment to the patient. And despite its more compact size and lighter weight, with up to 15W of power it still has the energy to deliver effective laser treatments in short amounts of time.
LightForce devices benefit from the following features:
Empower IQ
LightForce’s Empower IQ delivery system gives the user real-time feedback on treatment speed to help them treat effectively. Each device’s hand-held laser applicator comes equipped with a sensor that tracks its speed during treatment and feeds back to the user via a colour-coded light. As soon as they begin treating too slowly the light changes from green to red to indicate they need to speed up; go too fast and it will turn yellow to tell them to slow down.
*Not included with LightForce FXi
Built-in protocols
LightForce products feature in-depth protocol settings that detect which head is in use and recommend the appropriate power level. This helps guide the user in matching applicator heads to power output levels, giving them extra confidence during treatments and reducing learning time.
influence® technology
influence® technology helps guide LightForce users in using the appropriate treatment settings for their patients. Simply enter the patient’s parameters based on condition, skin type, body type, and acuity, and the device will select the correct dose to be administered. These settings can then be saved in preparation for future sessions and adjusted as necessary.
Simunovic Z. (1996). Low level laser therapy with trigger points technique: a clinical study on 243 patients. Journal of clinical laser medicine & surgery, 14(4): 163–167.
Kheshie, A. R., Alayat, M. S., & Ali, M. M. (2014). High-intensity versus low-level laser therapy in the treatment of patients with knee osteoarthritis: a randomized controlled trial. Lasers in medical science, 29(4): 1371–1376.
Kitchen, S. S. & Partridge, C. J. (1991). A Review of Low Level Laser Therapy: Part I: Background, Physiological Effects and Hazards. Physiotherapy 77(3): 161-168.
Among the many impacts of the coronavirus pandemic, one of the least publicised is that of low back pain. Far more of us are currently working from home, often without the necessary ergonomic support of chairs and desks designed to prevent back problems, and as a result, physiotherapists are seeing a growing number of patients presenting with low back pain.
Among the many impacts of the coronavirus pandemic, one of the least publicised is that of low back pain. Far more of us are currently working from home, often without the necessary ergonomic support of chairs and desks designed to prevent back problems, and as a result, physiotherapists are seeing a growing number of patients presenting with low back pain.
One way of treating low back pain is with electrotherapy. The practice takes advantage of the high excitability of nerve fibres, stimulating them with electrical pulses to achieve a number of therapeutic effects. As well as pain relief, this includes stimulation to help strengthen muscles, meaning it can be used to address both the symptoms and causes of low back pain.
Treating the SYMPTOMS of low back pain with electrotherapy
Most acute low back pain is a result of injury to the muscles, ligaments, joints, or discs. The body’s reaction to injury is to instigate an inflammatory healing response, which can cause severe pain.
TENS (Transcutaneous Electrical Nerve Stimulation) uses electrical pulses to provide pain relief by blocking pain signals from reaching the brain. High frequency (HF) TENS, or sensory stimulation, uses pulses of 80-100 Hz and works via the gate control mechanism, inhibiting the transmission of pain signals to the brain while producing a pleasant tingling sensation. As a result, HF TENS is effective for providing patients with relief from the symptoms of lumbar pain.1
However, rather than just treat the cause of the pain, it’s important to also address the cause of the injury. Thankfully, electrostimulation also has an answer for this.
Treating the CAUSES of low back pain with electrotherapy
Sitting slumped over a desk while you work puts increased strain on the muscles and ligaments in your back, which can then lead to injury and low back pain. To address the cause of posture-related low back pain, we need to restore balance between the trunk flexors and extensors and strengthen our paraspinal and abdominal muscles to improve spinal stability and help us sit up straight. This is where NMES can help. 2,3
NMES (Neuro Muscular Electrical Stimulation) uses electrical pulses to produce muscle contractions, mirroring the impulse sent from the brain. NMES can be used as a standalone treatment, but is most effective when used in combination with voluntary exercise such as proprioceptive or functional rehabilitation.
By safely controlling the contractions, the muscles can be made to exert themselves much more than the patient would be capable of voluntarily, and without placing additional stress on joints. Additionally, NMES can help the patient to recruit the deep lumbar stabilizers.3,4 This allows patients to effectively and safely strengthen their trunk muscles during exercise, thereby helping to address the causes of low back pain.2,3
However, if symptoms remain, functional rehabilitation for low back pain can still be carried out by combining NMES and TENS in a single treatment. One device with this function is Chattanooga’s Intelect Mobile 2.
Intelect Mobile 2 – the next generation in electrotherapy
Intelect Mobile 2 is an innovative device designed to provide clinicians with everything they need for effective electrotherapy treatment, and comes in three different configurations, STIM, ULTRASOUND, and COMBO.
All three options include an intuitive touchscreen user interface, a library of suggested protocols, and Bluetooth connectivity for easy software updates. And as the name suggests, the device is truly mobile, enabling it to be easily carried or mounted on a wheeled cart.
Intelect Mobile 2 STIM and COMBO provide 2-channel electrotherapy with over 20 different waveforms, offering therapists multiple treatment options. For instance, when treating a patient with low back pain, Channel 1 can be used to deliver TENS treatment for pain relief, while Channel 2 provides muscle stimulation to support functional rehabilitation exercises. Or therapeutic ultrasound can be used as an adjunct pain-relieving modality. 5
Altogether, Intelect Mobile 2 is an excellent option for therapists interested in using electrostimulation for treating not only low back pain, but also a range of other neuromuscular conditions.
1 Jauregui JJ, Cherian JJ, Gwam CU, Chughtai M, Mistry JB, Elmallah RK, Harwin SF, Bhave A, Mont MA. A Meta-Analysis of Transcutaneous Electrical Nerve Stimulation for Chronic Low Back Pain. Surg Technol Int. 2016 Apr;28:296-302.
2 Durmus D, Akyol Y, Alayli G, Tander B, Zahiroglu Y, Canturk F. Effects of electrical stimulation program on trunk muscle strength, functional capacity, quality of life, and depression in the patients with low back pain: a randomized controlled trial. Rheumatol Int. 2009 Jun;29(8):947-54.
3 Baek SO, Cho HK, Kim SY, Jones R, Cho YW, Ahn SH. Changes in deep lumbar stabilizing muscle thickness by transcutaneous neuromuscular electrical stimulation in patients with low back pain. J Back Musculoskelet Rehabil. 2017;30(1):121-127.
4 Coghlan S, Crowe L, McCarthypersson U, Minogue C, Caulfield B. Neuromuscular electrical stimulation training results in enhanced activation of spinal stabilizing muscles during spinal loading and improvements in pain ratings. Annu Int Conf IEEE Eng Med Biol Soc. 2011;2011:7622-5.
5 Goren A, Yildiz N, Topuz O, Findikoglu G, Ardic F. Efficacy of exercise and ultrasound in patients with lumbar spinal stenosis: a prospective randomized controlled trial. Clin Rehabil. 2010 Jul;24(7):623-31.
