Fuentes 2010

Effectiveness of Interferential Current Therapy in the
Management of Musculoskeletal Pain: A Systematic

Review and Meta-Analysis
Jorge P. Fuentes, Susan Armijo Olivo, David J. Magee
and Douglas P. Gross
PHYS THER. 2010; 90:1219-1238.
Originally published online July 22, 2010
doi: 10.2522/ptj.20090335
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Research Report
Effectiveness of Interferential Current

Therapy in the Management of
Musculoskeletal Pain: A Systematic
Jorge P. Fuentes, Susan Armijo Olivo, David J. Magee, Douglas P. Gross
J.P. Fuentes, BPT, MSc, is a PhD
student in the Faculty of Rehabili-
Background. Interferential current (IFC) is a common electrotherapeutic modal- tation Medicine, University of Al-
ity used to treat pain. Although IFC is widely used, the available information regarding berta, 350 Corbett Hall, Ed-
its clinical efficacy is debatable. monton, Alberta, Canada T6G
2G4, and Department of Physical
Purpose. The aim of this systematic review and meta-analysis was to analyze the Therapy, Catholic University of
Maule, Talca, Chile. Address all
available information regarding the efficacy of IFC in the management of musculo-
correspondence to Mr Fuentes at:
skeletal pain. jorgef@ualberta.ca.
S. Armijo Olivo, BScPT, MSc, PhD,

Data Sources. Randomized controlled trials were obtained through a comput- is affiliated with the Faculty of Re-
erized search of bibliographic databases (ie, CINAHL, Cochrane Library, EMBASE, habilitation Medicine, University
MEDLINE, PEDro, Scopus, and Web of Science) from 1950 to February 8, 2010. of Alberta.
D.J. Magee, BPT, PhD, is Professor,

Data Extraction. Two independent reviewers screened the abstracts found in Department of Physical Therapy,
the databases. Methodological quality was assessed using a compilation of items Faculty of Rehabilitation Medicine,
included in different scales related to rehabilitation research. The mean difference, University of Alberta.
with 95% confidence interval, was used to quantify the pooled effect. A chi-square D.P. Gross, PT, PhD, is Associate
test for heterogeneity was performed. Professor, Department of Physical
Therapy, Faculty of Rehabilitation
Data Synthesis. A total of 2,235 articles were found. Twenty studies fulfilled the Medicine, University of Alberta.
inclusion criteria. Seven articles assessed the use of IFC on joint pain; 9 articles [Fuentes JP, Armijo Olivo S, Magee
evaluated the use of IFC on muscle pain; 3 articles evaluated its use on soft tissue DJ, Gross DP. Effectiveness of in-
shoulder pain; and 1 article examined its use on postoperative pain. Three of the 20 terferential current therapy in the
studies were considered to be of high methodological quality, 14 studies were management of musculoskeletal
pain: a systematic review and
considered to be of moderate methodological quality, and 3 studies were considered
meta-analysis. Phys Ther. 2010;90:
to be of poor methodological quality. Fourteen studies were included in the 1219 1238.]
meta-analysis.
2010 American Physical Therapy
Association
Conclusion. Interferential current as a supplement to another intervention seems
to be more effective for reducing pain than a control treatment at discharge and more
effective than a placebo treatment at the 3-month follow-up. However, it is unknown
whether the analgesic effect of IFC is superior to that of the concomitant interven-
tions. Interferential current alone was not significantly better than placebo or other
therapy at discharge or follow-up. Results must be considered with caution due to the
low number of studies that used IFC alone. In addition, the heterogeneity across
studies and methodological limitations prevent conclusive statements regarding an-
algesic efficacy.
Post a Rapid Response to

this article at:
ptjournal.apta.org
September 2010 Volume 90 Number 9 Physical Therapy f 1219

Interferential Current Therapy in Management of Musculoskeletal Pain
S
uccessful management of mus- garding the scientific support of IFC apta.org). The literature search proce-
culoskeletal pain is a major chal- in the management of musculoskel- dure was complemented by manually
lenge in clinical practice. One etal pain. For example, a systematic searching the bibliographies of the
of the electrotherapeutic techniques review about the use of electrother- identified articles for key authors and
used for managing musculoskeletal apy for neck disorders13 excluded journals.
pain is interferential current therapy the analysis of IFC. Moreover, much
(IFC). The results of questionnaire of the IFC information is not written Study Selection and
surveys in England,1 Canada,2 and in English,10,14 22 and most articles Inclusion/Exclusion Criteria
Australia3,4 have shown that IFC is appear to be based on case re- Studies that met the following crite-
widely used by diverse clinicians ports,2325 clinical studies not includ- ria were considered for inclusion: (1)
throughout the world. ing a randomization process,26,27 let- randomized controlled trials (RCTs)
ters to the editor,28,29 clinical from journal publications in the En-
Interferential current therapy is the notes,30 experimental settings,3137 glish language (because the clinical
application of alternating medium- descriptive studies,8,12,38,39 or expe- application of IFC often is based on
frequency current (4,000 Hz) ampli- rience in the field40,41 instead of its coadjutant effect, studies in
tude modulated at low frequency methodologically qualified studies. which IFC was used as a cointerven-
(0 250 Hz).57 A claimed advantage tion also were included); (2) studies
of IFC over low-frequency currents is Thus, the objective of this systematic of male and female humans between
its capacity to diminish the imped- review and meta-analysis was to de- 18 and 80 years of age; (3) studies of
ance offered by the skin.6 Another termine the analgesic effectiveness subjects clinically diagnosed with a
advantage speculated for IFC is its of IFC compared with control, pla- painful musculoskeletal condition,
ability to generate an amplitude- cebo, or other treatment modalities such as muscle (eg, low back pain,
modulated frequency (AMF) parame- for decreasing pain in patients with neck pain), soft tissue (eg, tendinosis/
ter, which is a low-frequency current painful musculoskeletal conditions. tendinitis), or joint (eg, osteoarthri-
generated deep within the treatment tis) disorders; (4) regarding the type
area.6,8 10 Several theoretical physio- Method of interventions, all randomized com-
logical mechanisms such as the gate Search Strategy parisons of isolated or coadjutant IFC
control theory,11 increased circula- Relevant studies of IFC in musculo- applications versus placebo, control,
tion, descending pain suppression, skeletal pain management from 1950 another physical therapy interven-
block of nerve conduction, and pla- to February 8, 2010, were obtained tion, or another type of intervention;
cebo have been proposed in the lit- through an extensive computerized and (5) studies in which the out-
erature to support the analgesic ef- search of the following bibliographic come of interest was pain, as mea-
fects of IFC.5,8,12 databases: MEDLINE (1950 through sured by the use of a visual analog
week 4 of 2010), EMBASE (1988 scale (VAS) or numeric pain rating
Despite IFCs widespread use, infor- through week 5 of 2010), CINAHL scale (NRS). Exclusion criteria for
mation about it is limited. A review (1970 through February 8, 2010), this study were: (1) studies based on
of the literature reveals incomplete Scopus (1970 through February 8, animal data, (2) studies published in
and controversial documentation re- 2010), Cochrane Library (1991 through languages other than English, and
the first quarter of 2010), ISI Web of (3) studies including subjects who
Science (1970 through February 8, were healthy in experimental settings.
Available With 2010), and PEDro (Physiotherapy Evi-
This Article at dence Database) (1970 through Feb- Data Extraction and
ptjournal.apta.org ruary 8, 2010). The key words in- Quality Assessment
terferential, interferential therapy, Two independent reviewers screened
eAppendix 1: Search Results
interferential current, musculoskel- the abstracts of the publications
From the Different Databases
etal pain, electrotherapy, electro- found in the databases. The review-
eAppendix 2: Critical Appraisal analgesia, muscle pain, low back ers analyzed all articles initially se-
Sheet for Included Studies
pain, shoulder pain, hip pain, lected by the abstract or title for
The Bottom Line Podcast knee pain, neck pain, osteoarthri- the inclusion and exclusion criteria.
Audio Abstracts Podcast tis pain, and joint pain were used in Each criterion was graded on a
the search, including combinations of yes/no basis. In case of discrepancies
This article was published ahead of
print on July 22, 2010, at these words. For details regarding the between reviewers regarding whether
ptjournal.apta.org. search terms and combinations, see a particular article met a criterion,
eAppendix 1 (available at ptjournal. the ratings were compared and the
1220 f Physical Therapy Volume 90 Number 9 September 2010

criterion forms were discussed until been used in correlational studies to were grouped, evaluated for hetero-
a consensus was reached. determine reference values for qual- geneity, and pooled, if possible.
ity of association or agreement.43,44 When combining outcome data was
A critical appraisal was conducted to not possible, narrative, descriptive,
determine the methodological qual- The critical appraisal was indepen- and qualitative summaries were com-
ity of the final selected studies. We dently completed by the 2 review- pleted. In the present study, a meta-
used 7 scales (ie, Delphi List, PEDro, ers, and the results were compared. analysis was performed to quantify
Maastricht, Maastricht-Amsterdam List, At this stage, the intraclass correla- the pooled effect of IFC alone or as
Bizzini, van Tulder, and Jadad) com- tion coefficient (ICC) was calculated an adjunct treatment on pain inten-
monly used in the physical therapy using SPSS version 17 software* in sity when compared with placebo,
field to evaluate the methodological order to determine the agreement control group, or comparison inter-
quality of the included studies, com- between the reviewers for article vention. Because the pooled effect
piled in a set of 39 items.42 These grading. Any discrepancies were set- was based on the results of the VAS
items were grouped into 5 catego- tled through discussion. or NRS, the mean difference was
ries: patient selection, blinding, in- used to quantify the pooled effect.
tervention, outcomes, and statistics. Data Synthesis and Analysis RevMan 5.0 software was used to
Based on a recent systematic re- Studies investigating similar out- summarize the effects (ie, pooled
view,42 no one scale effectively de- comes and interventions and those mean differences) and construct the
termines the overall methodological providing clear quantitative data
quality of individual studies. For this
Copenhagen, Denmark: The Nordic Coch-
reason, we used all of them in a com- rane Centre, The Cochrane Collaboration,
* SPSS Inc, 233 S Wacker Dr, Chicago, IL 2008.
piled fashion. 60606.
The articles were evaluated on the

basis of only the information avail- The Bottom Line
able in the articles using the critical
appraisal sheet (eAppendix 2; avail-
able at ptjournal.apta.org). For each
What do we already know about this topic?
item listed on the critical appraisal Despite the widespread use of interferential current (IFC), information
sheet, a score of 1 was given when about its clinical effectiveness is limited and controversial. The pain-
the item was included in the article,
reducing effect of IFC, when applied alone or as part of a multimodal
and a score of 0 was given when the
treatment plan to treat musculoskeletal pain, has not been determined.
item was not included or the infor-
mation provided by the authors was What new information does this study offer?
not sufficient to make a clear state-
ment. In cases where the study did The application of IFC as part of a multimodal treatment plan appears to
not consider a particular item, the produce a modest pain-relieving effect in a broad spectrum of acute and
item was marked as not applicable chronic musculoskeletal conditions when compared with no treatment or
on the critical appraisal sheet. The placebo. In addition, the potential long-term effects of IFC versus placebo
scoring for each study was calcu- observed at 3-month follow-up are of interest.
lated by dividing the number of
items included by the number of ap- Interferential current alone was not significantly better than placebo and
plicable items. Finally, each study other interventions (ie, manual therapy, traction, or massage). However,
was graded as having low, moderate, heterogeneity across the included studies, along with methodological
or high methodological quality based limitations identified in these studies, prevents conclusive statements
on how many items from the critical regarding the analgesic efficacy of IFC.
appraisal were met. The cutoff was
determined as follows: 0 0.40low If youre a patient, what might these findings mean
methodological quality, 0.41 0.70 for you?
moderate methodological quality,
and 0.711.00high methodological If you are seeking pain treatment, IFC could be potentially effective in
quality. This criterion was deter- reducing musculoskeletal pain; however, its application should be in-
mined a priori to the quality assess- cluded as part of a multimodal treatment plan.
ment. Similar criteria for cutoffs have

ies not published in the English lan-

2,231 articles identified through guage10,14 22; (4) the absence of pain
database search (CINAHL,
Cochrane Library, EMBASE,
outcomes97105; (5) randomized trial
MEDLINE, PEDro, Scopus, 4 articles identified through manual search not used26,27,106 108; (6) use of a cur-
Web of Science)
rent other than IFC109,110; (7) use of
animal data111; and (8) unavailability of
the full text of the article.112114 At the
end of the critical appraisal stage,
there was an agreement of .83
2,081 articles excluded on the between the 2 raters. This ICC value
2,235 articles screened basis of the title and abstract

is considered as excellent agree-
ment according to the approach de-
scribed by McDowell.115

77 articles excluded:
154 full-text articles Characteristics of the Studies

assessed for eligibility 23 Not clinical studies All 20 studies reviewed in detail

(57 repeated): 24 Descriptive studies

97 finally selected 10 Not written in English were RCTs that examined the
09 No pain outcome included pain-reducing effectiveness of IFC.
05 Not a randomized trial
03 No full text available These studies analyzed the effects
02 Did not truly assess IFC of IFC for several diagnoses consid-
01 Animal data
ered to be either acute or chronic
20 studies included in the
qualitative synthesis painful conditions. Only 6 articles
(30%)48,54,56,57,61,63 examined the clin-
ical analgesic effectiveness of IFC as
a single therapeutic modality. The rest
4 Knee osteoarthritis pain
5 Low back pain of the articles included the applica-
2 Fibromyalgia/myofascial pain tion of IFC as a cointervention along
1 Jaw pain

14 studies included in the with other therapeutic alternatives such

1 Frozen shoulder pain
quantitative synthesis
1 Bicipital tendinitis pain as exercise,47,49,53,58 60,62,64 66 short-
(meta-analysis)
wave diathermy,51,59 hot packs,55,60
ice,58 myofascial release,55 neuromus-
Figure 1. cular electrical stimulation,52 infrared
Study screening process. IFCinterferential current therapy. radiation,51 and ultrasound.50,60,62 De-
tails of the studies characteristics are
shown in Table 1.
forest plots for all comparisons. For were selected as potential studies of
this analysis, the 95% confidence in- interest based on abstract review Methodological Quality of the
terval (CI) was used. A chi-square (Fig. 1). After full article review, only Studies
test for heterogeneity was per- 20 studies were deemed to fulfill the The results of the critical appraisal
formed (P.10).45 In the presence of initial selection criteria.47 66 The for the selected studies are pre-
clinical heterogeneity in the study kappa agreement between the re- sented in Table 2. Three of the 20
population or intervention, the Der- viewers in selecting articles after ap- studies were considered to be of
Simonian and Laird random-effects plying the inclusion and exclusion high methodological quality, 14 stud-
model of pooling was used based on criteria was perfect at 1.0. ies were considered to be of moder-
the assumption of the presence of ate quality, and 3 studies were con-
interstudy variability to provide a Seventy-seven studies were rejected sidered to be of poor quality. Even
more conservative estimate of the after applying the inclusion and ex- though the quality of most of the
true effect.45,46 If there was relative clusion criteria. The primary reasons studies was rated as acceptable (17
homogeneity, a fixed-effects model for exclusion from the study were: (1) studies were rated as being of mod-
was used to pool data.45 the use of subjects who were healthy erate or high quality), there are some
in an experimental setting3137,67 82; points regarding quality that need to
Results (2) descriptive studies in the form of be highlighted. Study flaws regarding
A total of 2,235 articles were found case reports, dissertations, or clinical patient selection were mainly related
in the database search. Of these, 154 notes,8,12,2325,30,38 41,69,8396; (3) stud- to description and appropriateness

Table 1.
Characteristics of the Studiesa
September 2010
Study Country Condition Sample Study Arms Outcomes Cointerventions Follow-up Treatment Results Strengths/Weaknesses
Quirk et al,59 England Knee OA 38 1. Active IFC ROM, pain (VAS), Exercises 3 and 6 mo 12 patients in the IFC Significant improvement Randomized
1985 exercises exercise endurance, exercise group, 12 in groups 1, 2 and 3 Confounders not
2. Active SWD maximum knee girth patients in the SWD (P.02, P.05, P.03, controlled
exercises exercise group, and 14 respectively) Reliability and validity of
3. Exercises patients in the exercise No significant difference outcomes not reported
group among groups Small sample size
Frequency of 0100 Hz No control/placebo
for 10 min and 130 Hz group included
for 5 min, 3 times a Poor description of
week for 4 wk intervention
Adedoyin et Nigeria Knee OA 30 1. Active IFC Pain (VAS) Exercises None 15 patients in IFC group Significant difference Randomized
al,47 2002 2. Placebo IFC and 15 patients in the between initial and final Clinicians blinded
placebo group pain rating in both Good control of
IFC: 4 electrodes (2 groups (P.01) confounders
placed lateromedially Significance difference Good description of
and 2 placed between 2 groups after intervention
anteroposteriorly), treatment (P.01). Pain Small sample size
frequency of 100 Hz for rating was found to be Validity of outcomes not
the first 15 min and 80 significantly better in the reported
Hz for the next 5 min, active IFC group than in
intensity (appreciable the placebo group.
sensation)
Both groups had
treatments and
mobilization exercise
twice a week for 4 wk
Adedoyin et Nigeria Knee OA 51, 5 were 1. IFC Functional disability Exercises None 15 patients in the TENS Significant time effect in Randomized
al,49 2005 excluded from the exercise (WOMAC), pain exercise group, 16 WOMAC and pain scores Clinicians blinded
analysis 2. TENS (10-point pain rating patients in the IFC (P.001) Sample size calculated
exercise scale) exercise group, and 15 No significant difference a priori and adequate
3. Exercise alone patients in the exercise between groups in Good description of
only group WOMAC and pain scores intervention
IFC: 2 electrodes (either (P.241, P.813) Confounders not
side of the knee All treatment protocols controlled
longitudinally), led to significant No control/placebo
frequency of 80 Hz reductions in pain and group included
continuous, intensity improvement in function Reliability of outcomes
(strong tingling not reported
sensation), 20-min
session, 2 sessions a
week for 4 wk
Defrin et al,54 Israel Knee OA 62 1. Active IFC Pain intensity (VAS), None None 11 patients in group 1, Significant improvement Randomized
2005 noxious pain relief (0100%), 11 patients in group 2, in groups 1 to 4 Good description of
stimulus morning stiffness 12 patients in group 3, compared with the intervention
unadjusted (10-cm line scale), 11 patients in group 4, control group (P.001) Small sample size
2. Active IFC active ROM 9 patients in the Significantly larger Confounders not
noxious (goniometer), placebo group, decrease in noxious controlled

stimulus electrically induced 8 patients in the groups (1 and 2) for Reliability and validity of
Volume 90 Number 9
adjusted pain threshold control group pain intensity (P.05) outcomes not reported
3. Active IFC (interferential current 2 electrodes (medial and pain thresholds Control and placebo
innocuous equipment) and lateral aspects of (P.01) when compared groups included
stimulus the knee); carrier with innocuous groups
unadjusted current of 4,000 Hz, (3 and 4)
4. Active IFC frequency between 30 No significant difference
innocuous and 60 Hz, intensity between adjusted and
stimulus 30% above (noxious) unadjusted groups
adjusted or 30% below (P.47)
5. Placebo IFC (innocuous) pain
6. Control threshold, raise
intensity (maintain
sensation) for adjusted
Physical Therapy f
groups, 12 sessions
every other day for
4 wk
1223
(Continued)
1224
Table 1.
Continued
f
Atamaz et al,51 Turkey Knee OA 85, 2 dropped out 1. Active IFC Movement (ROM), IR and SWD 1, 3, 6, 9, 40 patients in the Significant improvement Randomized
2006 at discharge IR SWD pain (VAS), and and 12 mo hyaluronan group in WOMAC, SF-36, and Clinicians blinded
2. Intra-articular function (SF-36, (20 NaHA, 20 hylan) pain scores in both Small sample size
hyaluronan WOMAC, 15 min and 42 patients in groups (P.05) No description of
walking time) the physical therapy Significant difference for physical therapy
group pain at rest, pain on interventions
Treatment applied 5 touch, and SF-36 in favor Confounders not
Physical Therapy
times a week for 3 of physical therapy controlled
wk with a series of IR, group at 1, 3, and 6 mo Reliability and validity of
SWD, and (P.05) outcomes not reported
interferential therapy Significant difference in No control/placebo
WOMAC scores in favor group included
of hyaluronan group
(P.05)
Burch et al,52 United Knee OA 116, 15 dropped 1. IFC NMES Pain and knee NMES None 57 patients in the IFC IFC NMES group Multicenter RCT
2008 States out at discharge 2. Low-current function (WOMAC), NMES group, 59 reduced pain and Clinicians blinded
intensity pain intensity (VAS), patients in the low- increased function Adherence tested
TENS quality of life (VAS) current TENS group compared with low- Sample size calculated
15 min of true IFC current intensity TENS a priori and appropriate
(5 KHz with a beat The IFC NMES group No true control/placebo
sweep frequency of group had a significantly group included
Volume 90 Number 9
1150 Hz) followed greater decrease in Confounders well
by 20 min of NMES overall pain VAS controlled
5 times a week for (P.038) Adverse effects reported
8 wk Reliability of outcomes
not reported
Werners et Germany Chronic LBP 152, 20 were lost 1. Active IFC Disability (Oswestry None 3 mo 74 patients in the IFC Significant improvement Randomized
al,63 1999 at 3-month 2. Lumbar Disability Index), group and 73 in both groups (P.05) Sample size calculated
follow-up traction pain (VAS) patients in the No significant difference a priori and appropriate
massage traction group between groups Confounders not
2 electrodes (placed controlled
paravertebrally in Reliability and validity of
pain area), frequency outcomes not reported
of 3060 Hz, six No control/placebo
10-min sessions over group included
1421 d
Hurley et al,57 Northern Acute LBP 60, 12 dropped 1. Active IFC Pain (PRI), disability None 3 mo 18 patients in the Significant improvement Randomized
2001 Ireland out at 3-mo painful area (RMDQ), generic painful area group, in pain severity, disability Good description of
follow-up The Back health status (EQ- 22 patients in the and health status for all treatment
Book 5D) spinal nerve group, groups at discharge Small sample size
2. Active IFC and 20 patients in (P.05) and at follow-up Confounders not
spinal nerve the control group (P.01) controlled
The Back 2 electrodes, carrier Significantly greater Clinical significance
Book frequency of 3,850 RMDQ score in spinal reported

3. Control (The Hz, frequency of nerve group (P.042) Reliability and validity of
Back Book) 140 Hz, 30 min outcomes not reported
23 treatment
sessions weekly until
discharge
Hurley et al,56 Northern Acute LBP 240, 82 lost at 1. Active IFC Functional disability None 6 and 12 52 patients in the MT Significant improvement Randomized

2004 Ireland 12-mo follow-up 2. Manipulative (RMDQ), pain (VAS, mo group, 55 patients in in all groups at Assessors blinded
therapy MPQ), quality of life the IFC group, and discharge, 6 mo, and Good description of
3. IFC (EQ-5D, SF-36), LBP 51 patients in the MT 12 mo (P.05) treatment
manipulative (recurrence, work IFC group No significant difference Sample size calculated
therapy absenteeism, 2 electrodes on spinal between groups (P.05) a priori and appropriate
analgesic nerve root placement, Adverse effects reported
consumption, carrier frequency of Clinical significance
additional health 3,850 Hz, frequency reported
care) of 140 Hz, 30 min No control/placebo
4 to 10 sessions over group included
a period of 8 wk Reliability and validity of
outcomes reported
(Continued)
September 2010
Table 1.
Continued
Lau et al,66 Hong Kong Acute LBP 110, 6 lost at 6- 1. IFC Pain (NRS), Education, 1, 3, and 6 55 patients in the Significant decrease in Randomized
2008 mo follow-up medication satisfaction medication, mo physical therapy pain (.025) and Allocation adequate
September 2010
education (Numeric Global mobility, and group and 55 increase in satisfaction at Assessors blinded
mobility and Rating of Change walking training patients in the discharge from the Sample size calculated
walking Scale), disability control group accident and emergency a priori
training (RMDQ) 4 suction-type department Intention-to-treat analysis
2. Walking electrodes applied No significant difference included
training around the painful between groups High follow-up adherence
(control area, sweep fre- (.025) at 1, 3, and 6 No placebo group included
group) quency 70130 Hz, mo follow-ups Homogeneity of subjects
intensity just below uncertain
the pain threshold,
15 min
1 or 2 sessions over a
24-hr period
Adedoyin et Nigeria Chronic LBP 39 1. Active IFC Pain intensity None None 13 patients in the Significant decrease in Randomized
al,48 2005 swing pattern (Verbal Semantic 11 group, 13 pain over time (P.001) Patients blinded
1 integral 1 Differential Scale) patients in the 66 No significant effect Good description of
2. Active IFC group, 13 patients in between groups treatments
swing pattern the 6 wedge 6 (P.063) Small sample size
6 integral 6 groups No control group
3. Active IFC 2 electrodes (spinal Confounders not controlled
swing pattern nerve root Validity and reliability of
6 wedge 6 correspondence to outcomes not reported
painful area),
frequency of 100 Hz
for burst group,
sweep set between
50 and 100 Hz for
the 66 and the 6
wedge 6 groups,
carrier frequency of
4,000 Hz in the
channel, channel 2
set to fluctuate
between 4,050 and
4,100 Hz
2 treatment sessions
daily for 2 times a
week for 3 wk
Zambito et Italy Chronic LBP 120 1. Active IFC Functional Exercise, analgesic 1 and 3 mo 45 patients in the At discharge, significant Randomized
al,65 2006 2. Active questionnaire medication active IFC group, 45 and similar improvement Sample size calculated
horizontal (Backill), pain (VAS), patients in the active in both the VAS and a priori and adequate
therapy analgesic horizontal therapy Backill score was Double blind approach
3. Sham consumption group, and 30 reported in all 3 groups Validity and reliability of
horizontal patients in the sham (P.05) outcomes not reported
therapy horizontal therapy The function and VAS Moderate description of
group scores continued to treatment
4 electrodes on a improve at 3 mo in the
standard dermatomal active groups compared
pattern; frequency of with control (placebo)
200 Hz, 10 min group (P.01)
5 sessions weekly for
2 wk

Volume 90 Number 9
Zambito et Italy Chronic LBP 115 1. Active IFC Functional Exercise, analgesic 1 and 3 mo 35 patients in the At discharge, significant Randomized
al,64 2007 2. Active questionnaire medication active IFC group, 35 and similar improvement Sample size calculated
horizontal (Backill), pain (VAS), patients in the active in both the VAS and a priori and adequate
therapy analgesic horizontal therapy Backill score was Double blind approach
3. Sham consumption group, and 35 reported in the 3 groups Validity and reliability of
horizontal patients in the sham (P.01) outcomes not reported
therapy horizontal therapy The function and pain Moderate description of
group scores continued to treatment
4 electrodes on a improve in the 2 active
standard dermatomal groups at weeks 6 and
pattern, frequency of 14 compared with the
200 Hz, 30 min control (placebo) group
(P.01)
Physical Therapy f
5 sessions weekly for
2 wk
(Continued)
1225
f 1226
Table 1.
Continued
Physical Therapy
van der The Unspecified 180, 1 dropped 1. Active IFC Recovery, functional Education and 3, 6, 9, and 34 patients in the No significant difference Randomized
Heijden et Netherlands shoulder soft out at 12-mo active US status (SDQ), chief exercises 12 mo active ET active US between groups up to Patients and assessors
al,62 1999 tissue follow-up 2. No IFC No complaint, pain group, 39 patients in 12 mo follow-up (95% blinded
condition US (VAS), clinical status, the active ET CI) Clinical significance
3. Sham IFC ROM (goniometer) dummy US group, reported
Sham US 39 patients in the Sample size calculated
dummy ET active a priori and adequate
US group, Good description of
33 patients in the treatment method
dummy ET dummy
US group,
35 patients in the no
adjuvant group
2 electrodes (1 in
deltoid muscle
Volume 90 Number 9
region, 1 over
homolateral erector
trunci muscles),
carrier frequency of
4,000 Hz, frequency
of 60100 Hz,
intensity of electric
paresthesia, 15 min,
12 sessions over
12 wk
Taskaynatan et Turkey Bicipital 47 1. IFC US Pain (VAS), ROM US hot packs 1 mo 21 patients in the IFC Statistical significant Randomized
al,60 2007 tendinitis hot packs (goniometer), exercises US hot packs improvement at Assessors blinded
exercises patient satisfaction exercises group, 26 discharge and 1-mo Poor description of
2. Steroid (NRS), disability patients in the steroid follow-ups in the steroid interventions
iophoresis (function section of iontophoresis US iontophoresis group Validity and reliability of
US hot the Pennsylvania hot packs (P.05) outcomes not reported
packs Shoulder Scale) exercises group Less dramatic Adverse effects reported
exercises AMF frequency improvement was No dropouts reported
0100 Hz, 15 min, reported for the IFC
15 sessions group at discharge and
1-mo follow-up (P.05)
Cheing et al,53 Hong Kong Frozen 74, 4 dropped out 1. Active IFC Shoulder function Exercise 1, 3, and 6 24 patients in the IFC Both active groups Randomized
2008 shoulder at 8-mo follow-up 2. Active electro- (Constant Murley mo group, 25 patients in showed a significant Patients and assessors
acupuncture Assessment Score), the electroacupunc- improvement at blinded
3. Control pain (VAS) ture group, 25 discharge and 6-mo Reliability and validity of
patients in the follow-up for function outcomes moderately
control group and pain scores (P.001) reported
4 suction-type No significant change Good description of
electrodes around the was found in the control treatment protocols
shoulder in a group, and no significant

coplanar difference was found
arrangement, between the 2 active
intensity just below groups (P.05)
the pain threshold,
AMF swept frequency
80120 Hz, 20 min
10 sessions over 4 wk
(Continued)
September 2010
Table 1.
Continued
Hou et al,55 Taiwan Cervical 71 1. Hot pack, Index of change in Hot pack, active None 21 patients in the hot Significant improvement Randomized
2002 myofascial active ROM pain threshold ROM, myofascial pack, active ROM in all groups (P.05) Good description of
September 2010
pain group (algometer), pain release group (B1); 13 Groups B2, B3, B4, B5, treatment
2. Hot pack, tolerance patients in the hot and B6 had significantly Sample size calculated
active ROM, (algometer), pain pack, active ROM, larger improvement than a priori
ischemic (VAS), and cervical ischemic compression group B1 (P.05) No control/placebo
compression ROM (goniometer) group (B2); 9 patients Groups B3, B5, and B6 group included
group in the hot pack, active had significantly larger Reliability and validity of
3. Hot pack, ROM, ischemic improvement than group outcomes not reported
active ROM, compression, TENS B2 (P.05)
ischemic group (B3); 10 Group B6 had significantly
compression, patients in the hot larger improvement than
TENS group pack, active ROM, group B4 (P.05)
4. Hot pack, stretch group (B4); 9 No significant difference
active ROM, patients in the hot among groups B3, B5,
stretch group pack, active ROM, and B6
5. Hot pack, stretch, TENS group
active ROM, (B5); 9 patients in the
stretch, TENS hot pack, active ROM,
group IFC, myofascial release
6. Hot pack, group (B6)
active ROM, 4 electrodes;
IFC, frequency of 100 Hz,
myofascial carrier frequencies of
release group 4,000 Hz and 4,100
Hz, 20 min
Almeida et al,50 Brazil Fibromyalgia 40, 23 dropped 1. Active IFC Pain (body map, US None 9 patients in the US Significant reduction in Randomized
2003 out US VAS), tender points, IFC group and 8 pain intensity and painful Investigator blinded
2. Placebo IFC (tender point patients in the sham areas in the combined Small sample size
US threshold), treatment group therapy group (P.001) Very low adherence
polysomnography, Carrier frequency of No significant difference (missing data 57.5%)
sleep questionnaire 4,000 Hz, frequency in sham treatment group Reliability and validity of
of 100 Hz, intensity in measurement not
the tactile sensation, reported
12 sessions for 4 wk
Taylor et al,61 United Chronic jaw 40 1. Active IFC Jaw pain (VAS), None None 20 patients in the IFC Significant improvement Randomization used
1987 States pain 2. Placebo IFC function (maximum group and 20 patients in both groups for pain Patients blinded
vertical jaw in the placebo group and maximal vertical jaw Confounders not
opening) 4 electrodes opening controlled
(extraorally 11.5 cm No significant difference Reliability and validity of
in front of the tragus between groups (P.05) outcomes not reported
of ear), frequency of Small sample size
90100 Hz for 15 min Good description of
and 4090 Hz for 5 treatment
min, intensity
(comfortable but not
too strong), 3
treatments (2472 hr
between treatments)
Jarit et al,58 United Postoperative 87 1. Active IFC Postoperative Ice, exercises None 28 patients in the ACL Significantly less pain and Randomized
2003 States knee pain 2. Placebo IFC edema, pain (VAS), group (14 IFC and 14 greater ROM for the Assessor blinded
pain medication, placebo IFC), 34 active IFC in all groups at Good description of
ROM (goniometer) patients in the all time points (P.05) treatment

Volume 90 Number 9
meniscectomy group Reliability and validity of
(17 IFC and 17 outcomes not reported
placebo IFC), 25
patients in the
chondroplasty group
(15 IFC and 10
placebo IFC)
4 electrodes,
frequency of 510 Hz
in first 14 min, 80
150 Hz in second 14
min, 3 times daily for
79 wk
Physical Therapy f
a
OAosteoarthritis, IFCinterferential current therapy, SWDshortwave diathermy, ROMrange of movement, VASvisual analog scale, TENStranscutaneous electrical nerve stimulation, WOMACWestern Ontario and McMaster
Universities Osteoarthritis Index, IRinfrared radiation, SF-3636-Item Short-Form Health Survey questionnaire, NMESneuromuscular electrical stimulation, PRIPain Rating Index, RMDQRoland-Morris Disability Questionnaire,
EQ-5DEuroQol EQ-5D questionnaire, MTmanual therapy, MPQMcGill Pain questionnaire, LBPlow back pain, USultrasound, SDQShoulder Disability Questionnaire, ETelectrotherapy, CIconfidence interval, NRSnumeric rating
1227
scale, AMFamplitude-modulated frequency, ACLanterior cruciate ligament.

of the randomization procedure and jaw pain,61 and myofascial syndrome week of therapy. One trial54 studied
concealment of allocation, with only pain.55 In contrast, the analysis of the effect of IFC on knee osteoarthri-
9 and 5 of the studies meeting these IFC in acute pain included just 4 ar- tis, and the other trial61 studied the
criteria, respectively. Items related ticles, 3 of them related to acute low effect of IFC on temporomandibular
to blinding were not achieved by back pain and 1 to postoperative joint pain. One study54 was rated of
the majority of the studies. Only 3 of knee pain. moderate methodological quality,
the studies used a double-blinded and the other study61 was rated of
design. Meta-analysis Results poor quality.61 In this comparison,
Fourteen studies were included in the both studies had opposite results re-
Testing subjects adherence to inter- meta-analysis (Fig. 1),47,49 56,60,61,63 66 garding the effectiveness of IFC
vention or having adequate adher- with an overall sample size of 1,114 when compared with a placebo
ence was another issue that was not patients. Six studies were excluded group (Fig. 2). The pooled mean dif-
accomplished by many studies (only for the following reasons: informa- ference (MD) obtained for this anal-
8 and 6 studies, respectively). Fur- tion regarding data variability (ie, ysis was 1.17 (95% CI1.70 4.05).
thermore, adverse effects were re- mean and standard deviation) was These results indicate that IFC alone
ported in only 3 of the studies, and not present,58,59 the unit of variabil- was not significantly better than pla-
none of the studies provided details ity included was different than the cebo at discharge.
of the follow-up period. standard deviation (ie, interquartile
range, median),57,62 the comparison Comparison 2: IFC Alone Versus
Despite the fact that the adequate included in the trial was not relevant Comparison Group on Pain
handling of dropouts is considered for the studys purpose,48 and the Intensity at Discharge
an important method used to pre- interventions included in the trial Two studies56,63 were included in
vent bias in data analysis, only 11 of were too heterogeneous51 (ie, IFC, this comparison. One study63 mea-
the analyzed studies included in- infrared radiation, shortwave dia- sured outcomes at discharge after 2
formation regarding the rate of thermy, and 2 drugs [sodium hyal- to 3 weeks of treatment, and the
withdrawals/dropouts. The outcome uronate and hylan G-F 20]). other study56 measured outcomes af-
measures were not described well ter 8 weeks. One trial56 studied the
in terms of validity, reliability, or The 14 selected studies were chosen effect of IFC on acute low back pain,
responsiveness. because they provided complete in- and the other trial63 studied the ef-
formation on the outcomes evalu- fect of IFC on chronic low back pain.
Regarding statistical issues, it was un- ated and homogeneity regarding out- Both studies were of moderate meth-
certain whether sample size was ad- come measures. Of these studies, 4 odological quality. In this compari-
equate in 15 of the studies. Intention- studies54,56,61,63 addressed the anal- son, both studies agreed that IFC was
to-treat analysis was used only in 11 gesic effect of IFC alone and 10 not significantly better than manual
of the studies. Finally, it also was studies47,49,50,52,53,55,60,64 66 evaluated therapy or traction and massage
unclear whether extraneous factors the effect of IFC applied as adjunct (Fig. 3). The pooled MD obtained for
such as equipment calibration or in a multimodal treatment protocol. this analysis was 0.16 (95%
medications during the study could In addition, of these 14 studies, 3 CI0.62, 0.31). These results indi-
affect the treatment responsiveness studies53,54,66 compared the effective- cate that IFC alone was not signifi-
for IFC. For example, only 2 studies ness of IFC with a control group, cantly better than any of the compar-
(10%) reported that the IFC equip- 6 studies47,50,54,61,64,65 investigated isons at discharge from therapy.
ment was calibrated during the study IFC against placebo, and 7 stud-
procedure. ies49,52,53,55,56,60,63 compared IFC with Comparison 3: IFC as a
another intervention such as manual Supplement to Another
IFC and Type of Pain therapy or exercise. Treatment Versus Control Group
Management on Pain Intensity at Discharge
The effect of IFC has been studied Comparison 1: IFC Alone Versus Three studies53,54,66 were included in
predominantly in patients with Placebo Group on Pain Intensity this comparison. Two studies53,54
chronic painful conditions (16 of at Discharge used a 4-week discharge period, and
20 trials examined). These condi- Two studies54,61 were included in one study66 used a one-day discharge
tions included knee osteoarthri- this comparison. One study54 mea- period. One trial54 studied the effect
tis,47,49,51,52,54,59 chronic low back sured outcomes at discharge after 4 of IFC on knee osteoarthritis, an-
pain,48,63 65 shoulder soft tissue weeks of therapy, and the other other trial53 studied the effect of IFC
pain,53,60,62 fibromyalgia,50 chronic study61 measured outcomes after 1 on frozen shoulder, and the third tri-

Table 2.
Methodological Quality of the Studiesa
Item Scoring
September 2010
Patient Selection Blinding Interventions Outcomes Statistics
Score/
Study 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 Rating
Adedoyin et al,47 2002 0 0 1 0 0 1 0 0 1 1 0 0 1 1 1 0 0 0 0 n/a n/a n/a 0 n/a n/a n/a 1 1 1 0 0 1 1 1 1 0 0 1 1 0.48
Moderate
Adedoyin et al,48 2005 1 1 1 0 0 1 0 0 0 1 0 0 1 n/a 0 0 0 0 0 0 0 0 0 n/a n/a n/a 1 1 1 0 0 0 1 1 1 0 0 1 0 0.37 Poor
Adedoyin et al,49 2005 1 1 1 0 0 1 0 0 1 1 0 0 1 0 1 1 1 0 0 1 1 1 0 n/a n/a n/a 1 1 1 1 0 0 1 0 1 1 1 1 0 0.61

Moderate
Almeida et al,50 2003 1 1 1 0 0 0 0 1 1 1 0 0 1 1 0 0 0 0 0 1 0 0 0 n/a n/a n/a 1 1 1 0 0 0 1 1 1 0 0 1 0 0.44

Moderate
Atamaz et al,51 2006 1 1 1 0 0 1 0 0 0 0 0 0 0 n/a 1 0 0 0 0 1 1 1 0 0 1 1 1 1 1 0 0 0 1 1 1 0 0 1 0 0.45

Moderate
Burch et al,52 2008 1 1 1 1 1 1 0 1 1 1 0 0 1 0 0 0 0 1 0 1 1 1 1 n/a n/a n/a 1 1 1 1 0 0 1 1 1 1 0 1 0 0.72 High
Cheing et al,53 2008 1 1 1 0 0 1 1 0 1 0 0 0 1 1 0 0 0 1 0 1 1 1 0 0 1 1 1 1 1 1 0 1 1 1 1 0 0 1 1 0.61

Moderate
Defrin et al,54 2005 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 1 1 0 0 0 0 0 0 n/a n/a n/a 1 1 1 0 0 0 1 1 1 0 0 1 0 0.42

Moderate
Hou et al,55 2002 1 1 1 0 0 0 0 0 0 0 0 0 1 0 1 1 1 1 1 n/a n/a n/a 0 n/a n/a n/a 1 0 1 0 0 0 1 1 1 1 0 1 1 0.51
Moderate
Hurley et al,56 2004 1 1 1 1 1 1 0 0 0 0 0 0 1 0 1 0 1 1 1 1 0 1 1 0 1 1 1 0 1 1 0 1 1 1 1 1 0 1 1 0.66

Moderate
Hurley et al,57 2001 1 1 1 1 1 1 0 0 0 0 1 0 1 1 0 0 0 0 0 1 1 1 0 0 1 1 1 1 1 1 0 1 1 0 1 1 0 1 1 0.61

Moderate
Jarit et al,58 2003 1 1 1 0 0 1 0 1 1 1 1 0 1 1 1 0 1 1 0 0 0 0 0 0 1 1 1 1 1 0 0 0 1 0 1 0 0 1 0 0.54

Moderate
Lau et al,66 2008 1 1 1 1 1 0 0 1 1 0 0 0 1 0 1 0 1 1 1 1 1 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0.72 High
Quirk et al,59 1985 1 1 1 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 1 1 1 0 0 0 1 1 1 0 0 0 0 0 1 0 0 0 0 1 0 0.36 Poor
Taskaynatan et al,60 1 1 1 0 0 1 0 0 1 0 0 0 0 n/a 1 1 1 0 0 n/a n/a n/a 1 0 0 1 1 1 1 0 0 0 1 1 1 0 0 1 1 0.51

2007 Moderate
Taylor et al,61 1987 1 1 1 1 0 0 0 0 0 0 0 0 1 1 0 0 0 0 0 n/a n/a n/a 0 n/a n/a n/a 1 1 1 0 0 0 1 1 1 0 0 1 0 0.39 Poor
van der Heijden et al,62 1 1 1 1 0 1 0 1 1 1 0 0 1 n/a 1 1 1 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 1 1 1 1 0 1 1 0.78 High

1999
Werners et al,63 1999 1 1 1 1 1 1 0 0 0 0 0 0 1 n/a 0 0 0 1 1 1 1 0 0 0 0 1 1 0 1 0 0 0 1 1 1 1 1 1 1 0.56

Moderate

Volume 90 Number 9
Zambito et al,64 2007 1 1 1 1 0 0 1 1 1 1 0 0 1 1 1 1 1 0 0 n/a n/a n/a 0 0 1 1 1 0 1 0 0 0 1 1 1 1 1 1 1 0.67
Moderate
Zambito et al,65 2006 1 1 1 1 0 0 1 1 1 1 0 0 1 1 1 1 1 0 0 n/a n/a n/a 0 0 1 1 1 0 1 0 0 0 1 1 1 1 1 1 1 0.67

Moderate
Accomplished items 19 19 20 9 5 13 3 7 11 9 2 0 17 9 13 7 11 8 6 11 9 8 3 0 10 12 20 14 19 6 1 5 20 16 19 10 5 20 11
Total percentage 95 95 100 45 25 68 15 35 55 45 10 0 85 60 65 35 55 40 30 79 64 57 15 0 83 100 100 70 95 30 5 25 100 80 95 50 25 100 55
a 1eligibility criteria; 2described as randomized; 3randomization performed; 4randomization described as appropriate; 5randomization concealed; 6baseline comparability; 7described as double blind; 8blinding described an appropriate; 9blinding of investigator/assessor;
10blinding of subject/patient; 11blinding of therapist; 12blinding of the outcome (results); 13treatment protocol adequately described for the treatment and control groups; 14control and placebo adequate; 15cointerventions avoided or comparable; 16cointerventions
reported for each group separately; 17control for cointerventions in design; 18testing of subject adherence; 19adherence acceptable in all groups; 20description of withdrawals and dropouts; 21withdrawals/dropouts rate described and acceptable; 22reasons for dropouts;
23adverse effects described; 24follow-up details reported; 25follow-up period adequate; 26short follow-up performed; 27timing of outcomes comparable in all groups; 28description of outcome measures; 29relevant outcomes included; 30validity reported for main
Physical Therapy f
outcome measure; 31responsiveness reported for main outcome measure; 32reliability reported for main outcome measure; 33use of quantitative outcome measures; 34descriptive measures reported for the main outcome; 35appropriate statistical analysis included; 36sample
size calculated a priori; 37adequate sample size; 38sample size described for each group; 39intention-to-treat analysis included; n/anot applicable.
1229
IFC Alone Placebo

Study or Mean Difference Mean Difference
Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
Defrin et al,54 2005 2.1 0.5 12 0.5 0.7 9 51.4% 2.60 (2.06, 3.14)
Taylor et al,61 1987 1.75 1.96 20 2.08 1.53 20 48.6% 0.33 (1.42, 0.76)
Total (95% CI) 32 29 100.0% 1.17 (1.70, 4.05)
Heterogeneity: tau24.10, 222.33, df1 (P.00001), I296%
Test for overall effect: z0.80 (P.42)
Figure 2.
Forest plot of comparison: interferential current therapy (IFC) alone versus placebo treatment on pain intensity at 1 week and
4 weeks (data presented as change scores). IVinverse variance, 95% CI95% confidence interval.
al66 studied the effect of IFC on acute studies, ranging from 2 weeks64,65 to placebo condition. In addition, the
low back pain. Two studies included 4 weeks.47,50,54 Mean difference to heterogeneity among studies was
in this comparison were of moderate pool the data was used. In addition, I296%, which is considered sub-
methodological quality,53,54 and one 95% CI and the random-effects stantial according to Cochrane group
study was considered to be of high model were chosen. In this compar- guidelines.45 Therefore, these results
quality.66 In this comparison, the 3 ison, 3 studies47,50,54 of moderate should be interpreted with caution.
studies tended to significantly favor quality tended to significantly favor
IFC applied as a cointervention IFC as a cointervention when com- In this comparison, 2 studies64,65
when compared with the control pared with placebo. One study64 of provided follow-up data (3 months).
group (Fig. 4). The pooled MD ob- moderate methodological quality Thus, an analysis at the 3-month
tained for this analysis was 2.45 (95% tended to significantly favor the pla- follow-up was performed (Fig. 5,
CI1.69, 3.22). Thus, IFC applied as cebo group. One study of moderate lower part). The pooled MD ob-
a cointervention was more than 2 quality did not favor either IFC as a tained for this analysis was 1.85 (95%
points better, as measured with the cointervention or placebo (Fig. 5, CI1.47, 2.23). The 2 studies signif-
VAS, in reducing pain intensity when upper part).65 The pooled MD ob- icantly favored IFC when compared
compared with a control group in tained for this analysis was 1.60 (95% with the placebo. This finding indi-
these conditions. CI0.13, 3.34). This finding indi- cates that IFC as a cointervention
cates that although IFC as a cointer- was better than a placebo at decreas-
Comparison 4: IFC as a vention was statistically significantly ing pain intensity at the 3-month
Supplement to Another better than a placebo at decreasing follow-up.
Treatment Versus Placebo on pain intensity at discharge in condi-
Pain Intensity at Discharge tions such as osteoarthritis, chronic
Five studies47,50,54,64,65 were in- low back pain, and fibromyalgia,
cluded in this comparison. Different IFC tended to reduce pain in these
times of discharge were used in the conditions when compared with a
IFC Alone Comparison

Mean Difference Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random 95% CI IV, Random, 95% CI
Hurley et al,56 2004 2.13 2.49 65 1.99 2.5 63 29.1% 0.14 (0.72, 1.00)
Werners et al,63 1999 0.42 1.35 50 0.7 1.49 51 70.9% 0.28 (0.83, 0.27)
Total (95% CI) 115 114 100.0% 0.16 (0.62, 0.31)
Figure 3.
Forest plot of comparison: interferential current therapy (IFC) alone versus comparison treatment on pain intensity at 3 weeks
and 8 weeks (data presented as change scores). IVinverse variance, 95% CI95% confidence interval.

IFC Therapy as
Supplement Control Group
Mean Difference IV,
Study or Subgroup Mean SD Total Mean SD Total Weight Random, 95% CI Mean Difference IV, Random, 95% CI
Cheing et al,53 2008 3.02 1.94 23 0.08 2.13 24 23.0% 2.94 (1.78, 4.10)
Defrin et al,54 2005 2.1 0.5 12 0.7 0.7 8 38.9% 2.80 (2.24, 3.36)
Lau et al,66 2008 2.2 1.65 55 0.4 1.5 55 38.1% 1.80 (1.21, 2.39)
Total (95% CI) 90 87 100.0% 2.45 (1.69, 3.22)
Heterogeneity: tau20.31; 26.76, df2 (P.03), I270%
Figure 4.
Forest plot of comparison: interferential current therapy (IFC) as a supplemental treatment versus control treatment on pain
intensity at 1 day and 4 weeks (data presented as change scores). IVinverse variance, 95% CI95% confidence interval.
Comparison 5: IFC as a weeks49,53,60 to 2 months.52 Two ness of IFC as a cointervention for

Supplement to Another studies49,52 evaluated the effective- myofascial pain.
Treatment Versus Comparison ness of IFC as a cointervention
on Pain Intensity at Discharge for knee osteoarthritis, 2 studies53,60 One study55 compared IFC plus hot
Five studies49,52,53,55,60 were in- evaluated the effectiveness of IFC as packs, active range of motion, and
cluded in this comparison (Fig. 6). a cointervention for shoulder pain, myofascial release with 5 different
Different times of discharge were and 1 study55 evaluated the effective- treatment modalities; thus, different
used, ranging from 1 day55 to 4 analyses were run in order to deter-
IFC Therapy as
Supplement Placebo
Mean Difference Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
3.1.1 Pain at discharge (1 week, 2 weeks, 4 weeks)
Zambito et al,64 2007 1.9 0.78 35 2.6 1 35 21.5% 0.70 (1.12, 0.28)
Zambito et al,65 2006 1.8 1.27 45 1.7 1.65 30 21.0% 0.10 (0.60, 0.80)
Adedoyin et al,47 2002 6.87 1.2 15 4.5 2.79 15 18.6% 2.37 (0.83, 3.91)
Defrin et al,54 2005 2.1 0.5 12 0.5 0.7 9 21.3% 2.60 (2.06, 3.14)
Almeida et al,50 2003 4.2 2 9 0 1.82 8 17.6% 4.20 (2.38, 6.02)
Subtotal (95% CI) 116 97 100.0% 1.60 (0.13, 3.34)
3.1.2 Pain up to 3-month follow-up
Zambito et al,64 2007 3.8 1.1 35 2 0.71 35 76.1% 1.80 (1.37, 2.23)
65
Zambito et al, 2006 3.2 1.64 45 1.2 1.7 30 23.9% 2.00 (1.23, 2.77)
Subtotal (95% CI) 80 65 100.0% 1.85 (1.47, 2.23)
2 2 2
Heterogeneity: tau 0.00, 0.02, df1 (P.66), I 0%
Figure 5.
Forest plot of comparison: interferential current therapy (IFC) as a supplemental treatment versus placebo treatment on pain
intensity at 1-week, 2-week, 4-week, and 3-month follow-ups (data presented as change scores). IVinverse variance, 95%
CI95% confidence interval.

IFC as Supplement Comparison

Study or Mean Difference IV,
Subgroup Mean SD Total Mean SD Total Weight Random, 95% CI Mean Difference IV, Random, 95% CI
49
Adedoyin et al, 5.07 1.39 16 4.74 1.14 15 20.1% 0.33 (0.56, 1.22)
2005
Burch et al,52 2008 2.79 1.32 53 2.32 1.54 53 23.1% 0.47 (0.08, 1.02)
Cheing et al,53 3.17 1.94 23 3.04 1.97 24 18.0% 0.13 (0.99, 1.25)
2008
Hou et al,55 2002 3.34 1.14 9 0.77 1.8 21 18.5% 2.57 (1.50, 3.64)
(B1)
Taskaynatan et al,60 0.8 1.49 21 1.4 1.59 26 20.2% 0.60 (1.48, 0.28)
2007
Total (95% CI) 122 139 100.0% 0.55 (0.33, 1.44)
Figure 6.
Forest plot of comparison: interferential current therapy (IFC) as a supplemental treatment versus comparison treatment on pain
intensity at 1 day, 2 weeks, 4 weeks, and 2 months (data presented as change scores). IVinverse variance, 95% CI95%
confidence interval. B1hot pack active range of motion.
mine the effect of IFC as a cointer- manual therapy, traction, massage) chronic musculoskeletal pain at dis-
vention when compared with all of at discharge from physical therapy charge and at 3 months posttreat-
these modalities (sensitivity analy- treatment. However, few included ment, respectively. The pooled ef-
sis). We used the MD to pool the studies (27%) examined the clinical fect for IFC as a cointervention
data. In addition, 95% CI and the analgesic effectiveness of IFC as a versus control was 2.45 on the VAS
random-effects model were chosen. single therapeutic modality, and (95% CI1.69, 3.22). According to
most did not focus on a specific mus- some authors, this change is consid-
In this comparison, no clear trend culoskeletal disorder. We also ob- ered a clinically meaningful effect
favoring either IFC as a cointerven- served differences in length of treat- for acute painful conditions.116 119
tion or the comparison treatments ment (ie, 1, 2, 3, and 8 weeks) and However, in chronic pain, a more
was observed for any of the analyses type of pain (ie, acute or chronic), stringent criterion seems to oper-
performed (Fig. 6). The pooled MD indicating no consensus on optimal ate because a relative pain reduction
obtained for the various analyses was treatment parameters, which poten- of 50% or at least 3 cm on a VAS
0.55 (95% CI0.33, 1.44). The tially contributed to the nonsignifi- has been recommended for detect-
mean difference indicated that IFC as cance of the results. ing a clinically successful pain
a cointervention was no better than reduction.120,121
other conventional interventions Analysis of the Analgesic Effect of
such as exercise, transcutaneous IFC as Part of a Multimodal In addition, when IFC as a cointer-
electrical nerve stimulation, or ultra- Protocol (Cointerventions) vention was compared with placebo
sound plus hot packs at decreasing An important factor in this meta- at discharge, there was no statisti-
pain intensity at discharge. analysis was the inclusion and analy- cally significant difference between
sis of studies including the applica- the groups. At 3-month follow-up,
Discussion tion of IFC as a cointervention in a IFC as a cointervention obtained a
Analysis of the Analgesic multimodal treatment protocol. This better effect on the VAS, although
Effect of IFC Alone decision was clinically sound be- less pronounced than when com-
The results of this meta-analysis indi- cause IFC is used mainly as an ad- pared with a control group (pooled
cate that IFC applied alone as an in- junct treatment. The results of this effect1.85, 95% CI1.47, 2.23).
tervention for musculoskeletal pain study indicate that IFC as a cointer- Thus, it seems that although IFC ap-
is not significantly better than pla- vention is significantly better than plied as a cointervention may have a
cebo or comparison therapy (ie, control and placebo for reducing modest analgesic effect, the magni-

tude of the effect is not large enough on IFC effectiveness, especially in Adverse Effects
to be considered clinically relevant chronic pain. An important safety feature when ap-
when compared with placebo or plying electrotherapy modalities is
comparison interventions. Additionally, IFC has not been ap- the report of adverse effects. Al-
plied using a consistent treatment though IFC is considered a safe mo-
Because this is the first meta-analysis protocol. For example, similar AMF dality, its application has been asso-
looking at the analgesic effect of IFC, settings (80 Hz) were considered ciated with local adverse effects such
direct comparisons cannot be made. for treating either acute56,57 or as blisters, burns, bruising, and swell-
In a previous study, Johnson and chronic47,50,53,55,64,65 conditions. ing.127,128 Interestingly, only 3 stud-
Martinson122 concluded that transcu- Moreover, under the same condition ies52,56,60 included reports of adverse
taneous electrical nerve stimulation, (eg, osteoarthritis), the authors in- effects as a result of IFC treatment.
used mainly as an isolated inter- consistently applied fixed AMF fre- Two studies56,60 reported no compli-
vention, provided significant pain quencies (ie, 80 Hz)49 or sweep AMF cations, and one study52 reported the
relief when compared with a pla- frequencies (ie, 1150 Hz, 30 60 presence of muscle soreness in one
cebo intervention in a variety of Hz, 0 100 Hz).52,54,59 Although ex- subject. Reporting adverse effects
chronic musculoskeletal conditions. perimental evidence has challenged must be mandatory, not only for the
Although methodological differences the role of AMF as the main analgesic safety of patients, but also for the
are present between both meta- component of IFC,36,37,85,126 incon- professional integrity of therapists.
analyses, some similarities such as sistency in the use of this parameter
the final sample sizes included, the in clinical settings warrants consider- Methodological Elements
focus on chronic musculoskeletal ation. Based on the current evi- Affecting Observed Effect
conditions, and clinical heterogeneity dence, recommendations for opti- Even though the quality of the trials
make the comparison between these mal dosage when using IFC are not appraised generally was moderate,
2 meta-analyses worth considering. clear. It seems, however, that clinical there are some methodological bi-
evidence supports the fact that AMF ases common to these studies that
Some factors regarding IFC treat- should not be the most important could have had an impact on the
ment may have accounted for the parameter for clinical decision mak- results. Selection bias could have ex-
modest effect size observed. For ex- ing. This fact has been corroborated isted, as only 9 trials reported appro-
ample, although the stimulation of by recent experimental evidence as priate randomization and only 5 tri-
small-diameter fibers has been dem- well.80 Instead, the use of a sensory als reported concealment of
onstrated to produce a more positive level of intensity appears to be a con- allocation. Another potentially im-
effect for chronic pain when com- sistent factor for the majority of the portant bias was the lack of blinding,
pared with the stimulation of large- studies. Although some variations in especially of the patients (9 studies)
diameter fibers (A),54 the included the number of treatments and the and assessors (11 studies). The out-
studies, regardless of the type of treatment time exist, it seems that 10 come measure for this meta-analysis
pain, used stimulation parameters to 20 minutes of application for 2 to was pain, which is a subjective out-
that were related mainly to the stim- 4 weeks with a total of 12 sessions is come and dependent on the sub-
ulation of A fibers and the pain gate the most common treatment proto- jects report. Trials without appro-
mechanism.11,4750,52,53,56 58,61,62 Al- col for IFC.4751,53,54,59,60,62,64,65 priate randomization, concealment
though the stimulation of large- of allocation, and blinding tend to
diameter fibers is acknowledged to In this systematic review, 16 out of report an inaccurate treatment effect
produce a fast onset of analgesia, an 20 studies evaluated the role of IFC compared with trials that include
important shortcoming is its brief an- in chronic rather than acute pain. these features.129 131
algesic effect.123125 Thus, it is plau- Based on this fact, it seems that IFC
sible that in chronic pain, which was has been applied more often in the Other potential biases that could
the dominant condition in this re- management of chronic painful con- have affected the observed effects
view, the effectiveness of IFC under ditions. Interestingly, and apparently were the lack of an appropriate sam-
these stimulation parameters may in contrast to current clinical prac- ple size (only 5 of the trials reported
have been attenuated, resulting in a tice in which IFC is used mostly for adequate sample size) and the inap-
small effect in reported pain reduc- short-term pain relief, this meta- propriate handling of withdrawals
tion. Further research is needed to analysis provided information re- and dropouts (only 11 trials used
evaluate the effect of noxious stim- garding potential positive long-term intention-to-treat analysis). Report-
ulation (eg, small-diameter fibers) benefits from IFC.64,65 ing clinical significance of results
has become a relevant issue to dem-

onstrate the effectiveness of an in- mation about the selected studies. musculoskeletal painful conditions
tervention. Clinical significance pro- The 20 RCT articles included in this compared with no treatment or pla-
vides the clinician with adequate review covered a broad spectrum of cebo. Interferential current therapy
information regarding the clinical im- acute and chronic musculoskeletal combined with other interventions
pact of an intervention because it can conditions. Interferential current was shown to be more effective than
identify when a meaningful change is therapy was analyzed as isolated in- placebo application at the 3-month
produced.132 Despite this message, tervention, as well as part of a mul- follow-up in subjects with chronic
the report of clinically meaningful timodal treatment plan. In addition, low back pain. However, it is evident
changes in the present study was the study provided multiple analy- that under this scenario, the unique
largely neglected, with only 3 studies ses, including the comparison be- effect of IFC is confounded by the
including this component.56,57,62 tween IFC and placebo, the compar- impact of other therapeutic interven-
ison between IFC and control, and tions. Moreover, it is still unknown
The present study used a compila- IFC contrasted to different types of whether the analgesic effect of IFC is
tion of items from all of the scales interventions. superior to that of these concomi-
used in the studies in the physical tant interventions.
therapy literature. Although some of Limitations
the scales used in physical therapy Outcome level. A main limitation When IFC is applied alone, its effect
(ie, PEDro, Jadad) have been vali- of this meta-analysis is the presence does not differ from placebo or other
dated in some way, our recent anal- of clinical heterogeneity in the study interventions (ie, manual therapy,
ysis of health scales used to evaluate population in most of the compari- traction, or massage). However, the
methodological quality determined sons, casting some doubt on the va- small number of trials evaluating the
that none of these scales are ade- lidity of our results. isolated effect of IFC, heterogeneity
quate for that use alone.42 Therefore, across studies, and methodological
it was decided that all of these scales Study and review level. A poten- limitations identified in these studies
would be used to assess methodolog- tial limitation is the omission of prevent conclusive statements re-
ical quality, and we used a compila- nonEnglish-language publications; garding its analgesic efficacy.
tion of items to provide a compre- however, English is considered the
hensive and sensitive evaluation of primary scientific language. It also Implications for Research
the quality of individual trials. How- has been reported that language- Because only 4 studies that evaluated
ever, further research investigating restricted meta-analyses only mini- the isolated effect of IFC were iden-
methodological predictors for deter- mally overestimate treatment effects tified, and these studies had mixed
mining trial quality in physical ther- (2% on average) compared with results, further research examining
apy is needed. language-inclusive meta-analyses.114 this issue is needed, ideally in homo-
Therefore, language-restricted meta- geneous clinical samples. Further re-
Summary of Evidence analyses do not appear to lead to search also is needed to study the
As an isolated treatment, IFC was not biased estimates of intervention ef- effect of IFC on acute painful condi-
significantly better than placebo or fectiveness.133,134 Applicability of re- tions. Also of interest would be the
other interventions. Conversely, sults about the isolated effect of IFC study of the effect of IFC in chronic
when included in a multimodal treat- on musculoskeletal pain also is lim- conditions using a theoretical frame-
ment plan, IFC displayed a pain- ited, as only 4 studies addressed this work for the selection of parameters
relieving effect (VAS reduction of issue. Another important limitation associated with suprasegmental anal-
over 2 points) compared with a con- is that this study included only pain gesic mechanisms (ie, noxious stim-
trol condition. as an outcome measure. It would be ulus) instead of sensory stimulation.
important to know whether out-
Strengths comes such as disability or function
Mr Fuentes, Dr Armijo Olivo, and Dr Gross
This meta-analysis is the first system- could have been modified by the ap- provided concept/idea/research design and
atic investigation regarding the pain- plication of IFC. writing. Mr Fuentes and Dr Armijo Olivo pro-
reducing effectiveness of IFC on vided data collection and analysis. Mr Fu-
musculoskeletal pain. A comprehen- Conclusions entes provided project management. Dr Ma-
gee and Dr Gross provided consultation
sive search was made of all the pub- Implications for Practice
(including review of manuscript before
lished research in this area over a Interferential current therapy in- submission).
wide range of years (1950 2010). In cluded in a multimodal treatment
This study was supported by the Alberta Pro-
addition, authors were contacted in plan seems to produce a pain-
vincial CIHR Training Program in Bone and
an attempt to have complete infor- relieving effect in acute and chronic

Joint Health, an Izaak Walton Killam scholar- 13 Kroeling P, Gross A, Houghton PE, Cer- 28 Van Tulder M. Randomized trial compar-
ship to Dr Armijo Olivo from the University of vical Overview Group. Electrotherapy ing interferential therapy with motorized
for neck disorders. Cochrane Database lumbar traction and massage in the man-
Alberta, the Provost Doctoral Entrance of Systematic Reviews. 2005;2: agement of low back pain in a primary
Award to Mr Fuentes from the University of CD004251. care setting [point of view]. Spine (Phila
Alberta, the Canadian Institutes of Health Pa 1976). 1999;24:1584.
14 Checchia GA, Balboni M, Franchi F, et al.
Research, the government of Chile (MECE- The use of vector field interference cur- 29 Emberson W. Interferential therapy is
SUP Program), the University Catholic of rents in the treatment of low back pain safe. Physiotherapy Frontline. 1995;
Maule, Chile, and the Physiotherapy Foun- associated with muscle tension [in Ital- 1:10.
ian]. Riabilitazione. 1991;24:43 49.
dation of Canada through an Ann Collins 30 Ganne JM. Interferential therapy. Aust J
Whitmore Memorial Award to Dr Armijo 15 Checchia GA, Pezzoli R, Gorini L, et al. Physiother. 1976;22:101110.
Electrotherapy in the treatment of shoul-
Olivo. 31 Cheing GL, Hui-Chan CW. Analgesic ef-
der pain [in Italian]. Riabilitazione. fects of transcutaneous electrical nerve
1991;24:121127.
This article was received October 13, 2009, stimulation and interferential currents on
and was accepted May 14, 2010. 16 Gelecek N, Akyol S, Algun C. The com- heat pain in healthy subjects. J Rehabil
parison of the effect of interferential cur- Med. 2003;35:1519.
DOI: 10.2522/ptj.20090335 rent and magnetotherapy applications on 32 Johnson MI, Tabasam G. A single-blind
pain in the patients with ostearthritis of placebo-controlled investigation into the
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Effectiveness of Interferential Current Therapy in the
Management of Musculoskeletal Pain: A Systematic
Jorge P. Fuentes, Susan Armijo Olivo, David J. Magee
and Douglas P. Gross
PHYS THER. 2010; 90:1219-1238.
Originally published online July 22, 2010
doi: 10.2522/ptj.20090335
References This article cites 123 articles, 9 of which you can access
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Effectiveness of Interferential Current Therapy in the

Management of Musculoskeletal Pain: A Systematic

Online-Only Material http://ptjournal.apta.org/content/suppl/2010/08/23/90.9.12

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Effectiveness of Interferential Current

S. Armijo Olivo, BScPT, MSc, PhD,

D.J. Magee, BPT, PhD, is Professor,

Post a Rapid Response to

September 2010 Volume 90 Number 9 Physical Therapy f 1219

1220 f Physical Therapy Volume 90 Number 9 September 2010

The articles were evaluated on the

September 2010 Volume 90 Number 9 Physical Therapy f 1221

ies not published in the English lan-

154 full-text articles Characteristics of the Studies

(57 repeated): 24 Descriptive studies

14 studies included in the with other therapeutic alternatives such

1222 f Physical Therapy Volume 90 Number 9 September 2010

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Book frequency of 3,850 RMDQ score in spinal reported

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scale, AMFamplitude-modulated frequency, ACLanterior cruciate ligament.

1228 f Physical Therapy Volume 90 Number 9 September 2010

Adedoyin et al,48 2005 1 1 1 0 0 1 0 0 0 1 0 0 1 n/a 0 0 0 0 0 0 0 0 0 n/a n/a n/a 1 1 1 0 0 0 1 1 1 0 0 1 0 0.37 Poor

Adedoyin et al,49 2005 1 1 1 0 0 1 0 0 1 1 0 0 1 0 1 1 1 0 0 1 1 1 0 n/a n/a n/a 1 1 1 1 0 0 1 0 1 1 1 1 0 0.61

Almeida et al,50 2003 1 1 1 0 0 0 0 1 1 1 0 0 1 1 0 0 0 0 0 1 0 0 0 n/a n/a n/a 1 1 1 0 0 0 1 1 1 0 0 1 0 0.44

Atamaz et al,51 2006 1 1 1 0 0 1 0 0 0 0 0 0 0 n/a 1 0 0 0 0 1 1 1 0 0 1 1 1 1 1 0 0 0 1 1 1 0 0 1 0 0.45

Burch et al,52 2008 1 1 1 1 1 1 0 1 1 1 0 0 1 0 0 0 0 1 0 1 1 1 1 n/a n/a n/a 1 1 1 1 0 0 1 1 1 1 0 1 0 0.72 High

Cheing et al,53 2008 1 1 1 0 0 1 1 0 1 0 0 0 1 1 0 0 0 1 0 1 1 1 0 0 1 1 1 1 1 1 0 1 1 1 1 0 0 1 1 0.61

Defrin et al,54 2005 1 1 1 0 0 0 0 0 0 0 0 0 1 1 1 1 1 0 0 0 0 0 0 n/a n/a n/a 1 1 1 0 0 0 1 1 1 0 0 1 0 0.42

Hurley et al,56 2004 1 1 1 1 1 1 0 0 0 0 0 0 1 0 1 0 1 1 1 1 0 1 1 0 1 1 1 0 1 1 0 1 1 1 1 1 0 1 1 0.66

Hurley et al,57 2001 1 1 1 1 1 1 0 0 0 0 1 0 1 1 0 0 0 0 0 1 1 1 0 0 1 1 1 1 1 1 0 1 1 0 1 1 0 1 1 0.61

Jarit et al,58 2003 1 1 1 0 0 1 0 1 1 1 1 0 1 1 1 0 1 1 0 0 0 0 0 0 1 1 1 1 1 0 0 0 1 0 1 0 0 1 0 0.54

Lau et al,66 2008 1 1 1 1 1 0 0 1 1 0 0 0 1 0 1 0 1 1 1 1 1 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0.72 High

Quirk et al,59 1985 1 1 1 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 1 1 1 0 0 0 1 1 1 0 0 0 0 0 1 0 0 0 0 1 0 0.36 Poor

Taskaynatan et al,60 1 1 1 0 0 1 0 0 1 0 0 0 0 n/a 1 1 1 0 0 n/a n/a n/a 1 0 0 1 1 1 1 0 0 0 1 1 1 0 0 1 1 0.51

van der Heijden et al,62 1 1 1 1 0 1 0 1 1 1 0 0 1 n/a 1 1 1 1 1 1 1 1 0 0 1 1 1 1 1 1 1 0 1 1 1 1 0 1 1 0.78 High

Werners et al,63 1999 1 1 1 1 1 1 0 0 0 0 0 0 1 n/a 0 0 0 1 1 1 1 0 0 0 0 1 1 0 1 0 0 0 1 1 1 1 1 1 1 0.56

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Zambito et al,65 2006 1 1 1 1 0 0 1 1 1 1 0 0 1 1 1 1 1 0 0 n/a n/a n/a 0 0 1 1 1 0 1 0 0 0 1 1 1 1 1 1 1 0.67

Total percentage 95 95 100 45 25 68 15 35 55 45 10 0 85 60 65 35 55 40 30 79 64 57 15 0 83 100 100 70 95 30 5 25 100 80 95 50 25 100 55

IFC Alone Placebo

Total (95% CI) 32 29 100.0% 1.17 (1.70, 4.05)

Heterogeneity: tau24.10, 222.33, df1 (P.00001), I296%

Test for overall effect: z0.80 (P.42)

IFC Alone Comparison

Total (95% CI) 115 114 100.0% 0.16 (0.62, 0.31)

Heterogeneity: tau20.00, 20.64, df1 (P.42), I20%

Test for overall effect: z0.66 (P.51)

1230 f Physical Therapy Volume 90 Number 9 September 2010

Total (95% CI) 90 87 100.0% 2.45 (1.69, 3.22)

Heterogeneity: tau20.31; 26.76, df2 (P.03), I270%

Test for overall effect: z6.28 (P.00001)

Comparison 5: IFC as a weeks49,53,60 to 2 months.52 Two ness of IFC as a cointervention for

3.1.1 Pain at discharge (1 week, 2 weeks, 4 weeks)

Almeida et al,50 2003 4.2 2 9 0 1.82 8 17.6% 4.20 (2.38, 6.02)

Subtotal (95% CI) 116 97 100.0% 1.60 (0.13, 3.34)

Heterogeneity: tau23.59, 2112.03, df4 (P.00001), I296%

Test for overall effect: z1.81 (P.07)

3.1.2 Pain up to 3-month follow-up

Subtotal (95% CI) 80 65 100.0% 1.85 (1.47, 2.23)

Test for overall effect: z9.57 (P.00001)