Electrical Stimulation Goals and Treatment

Adapted from Therapeutic Modalities: Art & Science, Knight & Draper (2008) for KIN 195

Competencies for Therapeutic Modalities

TM-C2 Explain the principles of physics, including basic concepts associated with the electromagnetic and acoustic spectra (e.g., frequency, wavelength) associated with therapeutic modalities. TM-C3 Explain the terminology, principles, basic concepts, and properties of electric currents as they relate to therapeutic modalities. TM-C4 Describe contemporary pain-control theories.

Competencies for Therapeutic Modalities, cont.

TM-C6 Explain the body's physiological responses during and following the application of therapeutic modalities. TM-C7 Describe the electrophysics, physical properties, biophysics, patient preparation and modality set-up (parameters), indications, contraindications, and specific physiological effects associated with commonly used therapeutic modalities. TM-C8 Identify appropriate therapeutic modalities for the treatment and rehabilitation of injuries and illness.

Basics of Electricity
Must understand why as well as how to use electrical stimulation. Or Youll be a knobologist.

Review: Requirements for Ion Migration: Chemical Effects

Must have continuous monophasic DC electron flow to cause ion migration. Moving electrons against gradient
Like pushing a car uphill When you pause, it rolls back down.

Why does a twin-pulse high-volt current not produce a chemical effect?

Review: Polarization & Action Potentials

Stimulation requires a polarized membrane (between inside and outside of nerve membrane).
More positive ions than negative ions outside nerve and more negative ions than positive ions inside membrane When polarized, membranes have a potential of 70 to 90 mV between inside and outside of membrane

Review: Polarization and Action Potentials (cont.)

Nerve action potential eventually causes
An ascending sensory impulse to the brain

Or
A descending muscle action potential

Muscle action potential causes muscle contraction.

Review: Polarization and Action Potentials (cont.)

Nerve repolarizes quickly. Absolute refractory periods vary from 0.4 to 2 msec
Depends on specific nerve

Review Excitability: Nerve Size and Depth

The larger the nerve, the easier it can be stimulated. The more superficial the nerve, the easier it can be stimulated. In a practical sense:
Large sensory nerves are more excitable than motor nerves. Motor nerves are more excitable than pain fibers.

Review Excitability: Rate or Frequency

Doesnt effect individual threshold
Effects torque as it approaches tetany Increased rate means increased fatigue rate.
tetany

5/sec

Review Electrodes: Physical Dimensions

Shape is unimportant
Most are round or square or rectangular.

Size and placement determine the number of motor units stimulated.

Review Electrode Function

Active electrode
Electrode under which the current density is great enough to elicit the desired response

Indifferent (dispersive) electrode

Electrode under which the current density is not great enough to elicit the desired response

Most Commonly Used Wave Forms

DC: DC IF: Polyphasic HV: Twin pulse LV: Biphasic and polyphasic burst (Russian) TENS: Biphasic

Review: Pulse and Cycle Characteristics

Pulse: finite period of charged particle movement, separated from other pulses by a finite time during which no current flows Made up of one or more phases

Review: Pulse and Cycle Characteristics (cont.)

Pulse named by number of phases
Monophasic
One phase Current flows in one direction only.

Biphasic
Two phases Current flows in both directions.

Polyphasic
Many phases

Review: Burst Characteristics

Burst
Finite series of pulses flowing for a finite time period followed by no current flow
Think of it as turning a pulse train or AC current on and off.

Burst interval
Time during which burst occurs

Interburst interval
Time between bursts, usually in milliseconds

Review: Current Timing & Modulation

Pulse width (pulse duration)
Time required for each pulse to complete its cycle Reported in microseconds or milliseconds

Short pulse duration: <150 sec Long pulse duration: >200 sec Interpulse interval
Time between successive pulses

Review: Surge Characteristics

Ramp up
Time during which the intensity increases Time during which pulses remain at maximum preset intensity Time during which the intensity decreases

Plateau

Ramp down

Commonly Used Wave Forms

(p.142)
Direct (galvanic) wave form
Pure DC current, used for iontophoresis

Commonly Used Wave Forms (p. 142, cont.)

Monophasic, rectangular, pulsed

Also called a modified square wave Similar to DC but modulated from AC input current On and off times are not necessarily equal

Commonly Used Wave Forms (p. 142, cont.)

Polyphasic, symmetrical, balanced, sinusoidal
Wave form generated and sold by utility companies

Commonly Used Wave Forms (p. 142, cont.)

Faradic wave form
Induced asymmetrical AC current Biphasic, asymmetric, unbalanced, spiked Positive portion: short duration, high amplitude, and spiked Negative portion: long duration, low amplitude, and curved

Commonly Used Wave Forms (p. 142, cont.)

Biphasic wave form
Symmetrical, balanced, rectangular, pulsed

Commonly Used Wave Forms (p. 142, cont.)

Russian wave form
Polyphasic, symmetrical, sinusoidal, burst

Developed by Russian scientist Kots; thus the name Initially a 2500 Hz AC current burst, modulated every 10 msec, now many frequency choices

Commonly Used Wave Forms (p. 142, cont.)

Twin pulse wave form
Monophasic, pulsed, twin spiked Common wave form of high-volt muscle simulators

Has been called high-volt galvanic and pulsed direct current However, not direct or galvanic current Result of misunderstanding physiology

Commonly Used Wave Forms (p. 142, cont.)

Interferential wave form
Symmetrical, sinusoidal, high frequency (20005000 Hz) AC

Two channels, with different frequencies, used simultaneously Two currents cause a tissue current amplitude modulation

Commonly Used Wave Forms (p. 142, cont.)

Two identical currents Interferential wave form: current amplitude modulation Two offset currents

Two opposite currents Usually accomplished with two different frequency currents

Use of Electrical Current Stimulation for Pain Relief

Transcutaneous electrical nerve stimulation (TENS) Interferential current therapy (IFC) Iontophoresis Neuromuscular electrical stimulation (NMES)

For all modalities

Know the effects, indications, contraindications, & precautions Verify the modality is set up correctly before treatment begins Prepare the patient psychologically & physically for the treatment Begin treatment conservatively and ask for patient feedback At the end of treatment, clean up the modality and instruct the patient about next treatment and activity level until then Maintain the machines appropriately

TENS
TENS Transcutaneous: through the skin Electrical Nerve: sensory Stimulation: depolarize Stimulate sensory nerves with pulsed current via surface electrodes

TENS: Physiological Aspects

Electrode placement
Usually at the site of pain

Clinician can change the patients perception of acute and chronic pain. Selective depolarization of afferent nerves

How does TENS work?

Many theories Gate system and sensory TENS 80-150 pps Endogenous Opiate system stimulated Motor TENS and brief-intense TENS
Low beat frequency 15 pps Slight muscle twitch

Brief Research Findings on TENS

Research is difficult. TENS has relieved pain associated with
Osteoarthritis Rheumatoid arthritis Dysmenorrhea Low back pain

Postoperative TENS

TENS
Advantages
1. Portable
a. Can be used during activity

Disadvantages
1. Eliminates pain; not cause of pain 2. May mask more serious problems 3. We don't know enough about it yet 4. May become a panacea (too reliant on it, maybe even after healthy)

2. Self-treatment 3. Alternative to cold during cryokinetics

TENS: Indications & Contraindications

Indications
1. Pain of peripheral origin 2. Acute pain 3. Chronic pain

Contraindications
1. Do not use on person with:
a. An implanted pacemaker b. History of heart disease

2. Do not treat transthoracic area 3. Discontinue use if a skin irritation develops

TENS: Precautions
G. Precautions
1. Treatment over an area with:
a. Impaired sensation b. Skin lesions (cuts, abrasions, new skin, recent scar tissue)

2. While driving or operating heavy machinery 3. Temporary decrease in pain does not mean cause of pain has gone. 4. Delicate unit, not a cheap radio
a. Treat it kindly.

Electrode placement techniques for TENS

Electrode placement
a. Over acupuncture or trigger points b. Directly over the pain c. Proximal or distal to pain d. Crisscross over pain (two-channel unit) e. Over motor point (helps with spasms) f. Dermatome placement

Application Parameters: TENS

Adjust pulse width and rate
a. Go through entire range and select most comfortable settings. b. Specific settings for specific conditions.
i. Acute pain: narrow pulse width (75 sec) and high pulse rate (80200 pps)
a) Pain relief is almost immediate, but short lasting (160 min)

ii. Chronic pain: wide pulse width (200 sec) and low pulse rate (15 pps)
a) Pain relief may take hr but will be long lasting (67 hr)

Application Parameters: TENS (cont.)

Length of application
1. Extremely variable 2. Some treat for 3060 min, others for hours

Frequency of application
1. Three or four times a day as needed for pain

Duration of therapy
1. Use until TENS is no longer effective.

Interferential Current
Interference or superimposition of two separate medium-frequency sinusoidal currents on one another Symmetrical, sinusoidal, medium frequency (20005000 Hz) AC Invented in 1950; used in United States by 1980s Fifth most frequently used physical agent

What Is IFC Therapy? (cont.)

Basic principle
Decrease tissue impedance (resistance) so simulation is less painful
Impedance at 50Hz = ~3200 Impedance at 4000 Hz = ~40 Current passes more easily through skin

Advantages of vector pattern

Surface and deep stimulation Targeted tissues for added benefit Treatment of easily localized pain Treatment of large areas Treatment of poorly defined pain

How Does IFC work? (cont.)

Example: One channel runs at 5000 Hz another at 5100 Hz
Use a dynamic vector (or scan for poorly
defined pain) Use target for easily localized pain

Treats most of the area bracketed by the electrodes (scan or dynamic vector)

Is IFC Therapy Effective? (cont.)

Those who have had success
Correctly position vector Use appropriate size and positioning of electrodes Use appropriate stimulation parameters Persevere, if pain relief is not immediately obtained

IFC advantages & disadvantages

Advantages
1. More comfortable than a TENS
a. Medium-frequency currents meet with less skin resistance than low frequency currents.
i. TENS uses low frequency currents

Disadvantages
1. Eliminates pain; doesn't deal with cause of the pain 2. May mask more serious problems 3. Few portable units available 4. Sometimes becomes a panacea

2. Stimulates tissues deeper than a TENS unit 3. Larger coverage area than TENS

IFC: Indications & Contraindications

Indications
1. Acute pain 2. Chronic pain 3. Muscle spasm 4. Pain that covers a large area

Contraindications
1. Do not use on a person who has:
a. Implanted pacemaker b. History of heart disease

2. Do not treat transthoracic area 3. Discontinue if skin irritation develops

IFC Precautions
Precautions
1. Be cautious when using IFC over:
a. Impaired sensation b. Skin lesions (cuts, abrasions, new skin, recent scar tissue, etc.)

2. Use caution when using IFC while driving or operating heavy machinery. 3. A temporary decrease in pain does not mean the cause of the pain has gone.

Application Parameters: IFC

Adjust pulse rate settings for specific injury
a. For acute pain
i. Use a high pulse rate of 80200 pps ii. Pain relief is almost immediate iii. Lasts only a few minutes to 1 hr

b. For chronic pain

i. Use a low pulse rate of 15 pps ii. Pain relief may take hr iii. May last 67 hr

Target or vector
a. Pain that is easily identifiable and pinpointed
i. Use target or vector buttons to move spot where current intersects to area directly over pain

b. Pain that is hard to pinpoint

i. Use dynamic vector

Application Parameters: IFC (cont.)

C. Length of application
1. 2030 min

D. Frequency of application
1. Once or twice daily, as needed for pain

E. Duration of therapy
1. Use until IFC is no longer effective.

NeuroMuscular Electrical Stimulation

NMES is used for
Muscle reeducation and prevention of disuse atrophy Decreasing muscle spasm Decreasing edema

History of NMES
1980 companies started manufacturing Russian current No North American scientist has been able to duplicate Kotss claims of 30% increase in force vs. voluntary contractions and lasting gains up to 40% in healthy athletes
Great amount of pain (as the current
amplitude was increased to try to replicate a voluntary muscle contraction)

Why NMES?
Used on patients who cannot perform a voluntary muscle contraction
Peripheral nerve innervation is intact, yet muscle is too weak to contract from atrophy, pain, immobilization, etc.

Promotes early AROM in postsurgical and immobilized limbs Break pain-spasm-pain cycle of muscle spasms

Dont Replace Strength Training with NMES

NMES recruits fibers in the opposite order than that of a voluntary contraction.
Machine = large fibers followed by small Voluntary = small fibers followed by large

Patient needs to move on to more traditional weight training ASAP.

Tetanic Contraction to break Muscle Spasm

Goals
Increase local circulation Remove metabolic wastes Mechanically stimulate muscle fibers Induce some muscle spasm fatigue

NMES for Decreasing Edema

Produce cyclic muscle contractions to help pump chronic edema
510 sec on; 510 sec off

NMES Effects
Effects
1. Muscle contraction
a. Increase blood flow b. Retard atrophy development c. Decrease and retard neuromuscular inhibitions d. Increase muscle relaxation; decrease spasm

2. Decrease pain
a. Possibly by decreasing muscle spasm

NMES Advantages & Disadvantages

C. Advantages
1. Can be applied to immobilized body part

D. Disadvantages
1. Sometimes becomes a panacea

NMES Indications & Contraindications

Indications
1. Residual or chronic muscle spasm 2. Any time normal neuromuscular function is not possible 3. Muscle strains 4. During cast immobilization or disuse atrophy 5. Pain owing to muscle spasm

Contraindications
1. Do not use:
a. On a person with a pacemaker b. Over the heart or brain c. Over recent or non-union fractures d. Over potential malignancies

NMES Precautions
G. Precautions
1. Be cautious over an area with:
a. Impaired sensation b. Skin lesions (cuts, abrasions, new skin, recent scar tissue) c. Decreased range of motion d. Extensive torn tissue

Application Parameters: NMES

C. Length of application
1. 1030 min 2. See individual manufacturers instructions.

D. Frequency of Application
1. As often as twice per day if separated by 34 hr

Iontophoresis: Basic Principle

 Like charges repel like charges,
 Drug ions are repelled or pushed into the underlying tissue.

 Two electrodes
One drug delivery One larger dispersive electrode

How Does Iontophoresis Work?

When an electrical DC current is applied
Positively charged electrode delivers positively charged drug ions into skin and surrounding tissues Negatively charged electrode delivers negatively charged drug ions into skin and surrounding tissues

Why Use Iontophoresis?

Delivering medicine such as antiinflammatories and pain relievers directly without the negative effects of
Painful needle injections Risk of infection from nonsterile needle injections Avoid the gastrointestinal side effects of NSAIDs and COX-2 inhibitors Localized drug delivery; doesnt travel through entire system Machine is Portable and easy to transport

Common Drug Ions Used in Sports Medicine

Dexamethasone
Negative ion Reduces inflammation by inhibiting biosynthesis of prostaglandins and various other inflammatory substances Negative ion Assists in dissolving calcium deposits and scar tissue in soft tissues

Acetate

Common Drug Ions Used in Sports Medicine (cont.)

Hydrocortisone
Positive ion Assists in decreasing tissue inflammation by inhibiting biosynthesis of prostaglandins

Lidocaine
Positive ion Assists in decreasing local pain by blocking nerve impulse transmission

Is Iontophoresis Effective?
Debate
Research has shown it to deliver medication from 6 to 20 mm below the skin

Effective in reducing pain and inflammation associated with

Plantar fasciitis Temporomandibular disorders Epicondylitis

When dexamethasone, lidocaine, or sodium salicylate is used

Ionto Advantages & Disadvantages

Advantages
Compared to injections:
 Virtually painless  Noninvasive, minimizing
 Risk of infection  Risk of tissue necrosis, tendon rupture, etc.

Disadvantages
1. Eliminates pain or inflammation
a. Doesn't deal with the cause of the pain/inflammation.

Compared to oral medications:

 Localized drug delivery, nonsystemic  Avoid risk of systemic side effects

2. Slight risk of electrode burns 3. Some believe transdermal drug delivery is not possible.

Iontophoresis Indications & Contraindications

Indications  Used to administer water-soluble ionic medications Contraindications  Damaged or denuded skin
 Recent scar tissue

 Drug allergies  Transcranial  Orbital region  Electrically sensitive support systems

 Pacemakers

Iontophoresis: Precautions
Precautions      Diabetes Pregnancy Over external metal fixation devices Elderly skin TMJ
 Dizziness  Metallic taste

Ionto: Drug Dose Calculation

Dosage (mA/min) = Current (mA) Treatment time (min) Examples:
40 mA/min = 4.0 mA (current) 10 min (time) 40 mA/min = 2.0 mA (current) 20 min (time) 24 mA/min = 2.0 mA (current) x 12 min (time)

Reported Sensation of Iontophoresis

 Some patients feel little or no sensation; others describe it as a tingling or warm sensation. The intensity of the sensation varies among patients and depends on the site being treated. These sensations usually decrease or disappear after a few minutes.

Typical Skin Reactions to Ionto

 DC causes capillary dilatation, leading to erythema (reddening) of the skin under one or both electrodes.  Less frequent: appearance of small fluidfilled bumps caused by the release of histamine from dermal mast cells
 Note: These skin reactions disappear over the course of a few minutes but may last longer in patients with particularly sensitive skin. Also, some patients with sensitive skin may react to the adhesive on the electrode.

Reduce Negative Effects from Iontophoresis

To help reduce the risk of skin irritation
Clean the skin with an alcohol scrub. After treatment, apply a lotion containing aloe vera. Increase the size of the anode or cathode to decrease current density. Increase the spacing between electrodes to decrease current intensity.

Application Parameters: Ionophoresis

C. Length of application
1. Dose specific

D. Frequency of application
1. Every other day

E. Duration of application
1. Up to 3 weeks

High Voltage Pulsed Current Stimulation for Wound Healing

Electrical stimulation for the purpose of repairing tissues includes management of open wounds and edema reduction. Production of a twin-peak, monophasic, pulsed current driven by its characteristically high electromotive force or voltage Positive or negative polarity

HVPC (cont.)
Versatile and can perform several functions:
Pain modulation Edema reduction Muscle reeducation and spasm reduction Wound healing

Characteristics of High-Volt Stimulator

Low volt stimulators generate <150 V High volt stimulators generate >150 V HVPC uses between 150 and 500 V. High peak voltages Low average current Twin peak monophasic waveform
Resembles a double spike with a fast rise followed by a fast decline

Short pulse widths (100200 sec) Pulse rates of 1200 Hz

HVPC: Uses & Techniques

Monophasic current used for
Pain reduction Disuse atrophy Reduction of edema Wound management

Monopolar or bipolar technique

Monopolar used when treatment is directed over a large area Bipolar used for muscle contraction or chronic pain

HVPC: Advantages
Less resistance to the current by the skin Short phase duration allows for moderately high-intensity muscle contraction with little discomfort
Other types of stimulators provide a stronger contraction Highly variable in its functions Can be used for

Pain modulation
a. Sensory level (acute pain) b. Motor level (chronic pain)

Edema reduction Treating muscle weakness Wound healing

HPVC: Disadvantages
Disadvantages
1. Cannot provide as strong of a contraction as NMES 2. Many arent portable. 3. Sometimes trial and error are needed to determine electrode polarity for wound healing. 4. Effects (muscle contraction) are as strong as low-volt units.

HPVC: Indications & Contraindications

Indications
1. Wound lesions (pressure sores, scarring from incisions) 2. Edema control and reduction 3. Residual or chronic muscle spasm (when low-volt unit unavailable) 4. Pain

Contraindications
1. Do not use on patient with pacemaker 2. Do not use over
a. Heart or brain b. Lumbar and abdominal area of pregnant women c. Potential malignancies d. Anterior cervical area

HPVC Precautions
G. Precautions
1. Be cautious when using HVPC over an area with:
a. Impaired sensation b. Extensive torn tissue c. Hemorrhagic area

2. Patients with epilepsy should be monitored during treatment.

HVPC: Edema Management

Curbing edema formation
HVPC is not DC Decreases the permeability of microvessels Decreases the leaking of vessels, reducing the number of plasma proteins and amount of fluid that leave the vessels to enter the interstitial spaces

HVPC: Edema Management (cont.)

Two protocols for curbing edema Water immersion
-Negative polarity -120 pps -90% of visible motor threshold -30 min treatments every 4 hr -Apply ASAP postinjury or as long as edema is still forming

Resolution of edema once formed

-Can be employed in a muscle pumping action to get rid of edema -Intensity increased until strong muscle contraction -Setting of 110 pps for muscle contraction

HVPC: Pain Modulation

Ineffective in reducing the pain of delayed-onset muscle soreness Yet has been shown to help relieve pain caused by muscle spasm

HVPC: Wound Management

How does HVPC stimulate wound repair?
Body possesses bioelectric currents in the vascular and interstitial tissues. Blood vessel walls, insulating tissue matrix, interstitial fluid, and intravascular plasma are capable of conducting bioelectricity. When tissues are damaged, an electrical potential is created between injured and noninjured tissues.

HVPC: Wound Management (cont.)

DC may stimulate cellular activity when injured. Stimulating dbridement of injured tissues Tissue regeneration and remodeling May speed up healing by promoting the natural healing process May develop a difference in potential between wound area and the surrounding healthy tissue Injury potential typically becomes positive 2448 hr after injury & negative 89 days after injury. As the wound heals, the difference slowly returns to baseline.
Can be used to enhance the natural process of tissue recovery and healing

HVPC: Electrode Polarity

Negative polarity
Increases Vascularity Stimulation of fibroblastic growth Collagen production Epidermal cell migration Inhibits bacterial growth

Positive polarity
Increases macrophages Promotes epithelial growth

HVPC: Electrode Polarity (cont.)

Most treatments begin with the negative polarity
Encourages blood clots to dissolve and increases the inflammatory by products
Necrotic tissues

Positive polarity encourages clot formation around the wound and granulation tissue.

Application Parameters: HVPC

D. Frequency of application
1. As often as three per day if separated by 34 hr

Microcurrent Electrical Nerve Stimulation

Therapeutic use of constant (DC) and pulsed (interrupted) currents where the stimulus amplitude is in the microamperage range Proposed Uses
Tissue healing Pain control Edema control Slow healing skin lesions

MENS Names
Many names of microcurrent
MENS does not accurately describe this device. Current intensity is too low (<1 mA) to cause motor nerve depolarization

Other than MENS, these devices have been referred to as:

Low-voltage pulsed microamp stimulation Biostimulation Bioelectric therapy Low-intensity direct current Low-intensity electrical stimulation

MENS: Theory
Brief research
No clear-cut research supporting the use of microcurrent therapy Positive effect in treating
Pressure ulcers Diabetic ulcers TMJ disorders

No effect in treating
DOMS Pressure ulcers Coracoacromial arch pain Surgically induced wounds

MENS: Theory (cont.)

Might play a positive role in wound healing, an area athletic trainers typically dont deal with It is safe.