A.THANGAMANI RAMALINGAMPT, MSc (PSY), MIAP

Almost 60 yrs old, popular last 25 years with numerous uses.

Waveform: • Twin-peak monophasic pulse

• phase duration: 25s, sometimes adjustable

• comfortable but weak current; polarity present but electrochemical (net DC) effect not harmful. Typical stimulation time does not exceed 1 hour

• Upto200µs

• Voltage more than 100 volts

Wound healing

Oedema reduction

Pain modulation

NMES

On vascular system

Amplitude (based on desired excitatory

response)

Pulse Rate (related to pain control theory

or motor response needed)

Mode - Continuous, Ramp-Surge,

Alternate

Robert Becker – 1962Theory - “Current of Injury”

• normal bioelectric system, nonexcitable tissues have a charge skin ----- deeper tissues +++++ neuraxis ++++++ periphery -------

• Wounds - system is disturbed & creates a “current of injury” that initiates tissue healing . . . inflammatory process, migration of cells, etc..

• Use of E-stim magnifies the “current of injury” to initiate, maintain, or speed the process.

Further research established• Wound tissue is (+) & skin

around is (-); this difference is the “skin battery” or “current of injury” and must exist for proper healing; if it fails or is disrupted, then slow/no healing can occur. E -stim can help restore the “skin battery”.

Further supported by evidence that many chronic wounds lost (+) polarity; e-stim w/ the anode (+) over the wound enhanced healing. (using DC)

If healing plateaued, switching polarity = good outcome

Monophasic twin-pulse current (HVPC)105 ppsAmplitude: submotorTime - 45 min, 5 days a weekWound packed with soaked gauze and

anode (+) placed over woundCathode placed 15 cm away, proximalRationale: Done to amplify the “current of

injury”

A naturally occurring process whereby signaling/messenger systems work via bioelectrical mechanisms. (Does not contradict the chemical model of human physiology; “chemotaxis”).

Process can be corrected and/or

enhanced by attraction of cells to the

wound thru use of anode (+) or cathode (-)• Leukocytes, fibroblasts, endothelial & epithelial

cells, etc.. all have polarity and can be electrically

attracted.

Treatment polarity depends on stage of

the wound

Monophasic twin-pulse current (HVPC)100 pps, no mention of pulse width Amplitude - just below motorTime - 60 min, 5 days a weekWound packed with soaked gauze Polarity - based on wound stateOther electrode placed 15 - 20 cm away

(proximal) to complete the circuitDone to amplify the “injury potential” or

“current of injury” and produce “galvanotaxic attraction”

Options• Directly over the wound

• Directly in the wound *

• Straddle the woundWOUND TREATED

Burns

Post surgical wounds

Hand injuries

Venous ulcers

Diabetic ulcers

6µA-1.4mA of DC current stills the growth

of micro organisms.

Current disrupts the homeostatic

mechanism of the organism.

Anodal current

Cathodal current

Dermal cell movement

Germicidal effect

Sedative effect

Increases blood flow

Germicidal effect

Clumping of leucocytes

Why not use LIDC ??: Studies have shown it to be effective• Much longer Rx time and

greater frequency of Rx

• electrochemical changes more pronounced & potentially harmful (due to pH changes in tissue)

HVPC has a shorter Rx time and less frequent, no harmful electrochemical changes in the tissue

Mechanisms by which biphasic or AC may enhance healing are not well-understood.

ESTR usually not used on well-healing wounds, more for chronic wounds

DOES NOT replace typical wound care

Suggest physician cooperation/agreement

Patient tolerance or refusal a potential issue based on the way you describe it.

OsteomyelitisMalignancies / neoplasmsCarotid sinus / laryngeal ms.Thru the thoraxDemand-type pacemakersOver topical agents containing metal ions

(iodine, mercurochrome)Others as previously learned; except for open

tissue

Negligible thermal& electrochemical effects

Cannot be used to treat denervated

muscles

Electrical stimulation for the treatment of wounds will only be covered for chronic Stage III or Stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers.

All other uses of electrical stimulation for the treatment of wounds are non-covered.

Chronic ulcers are defined as ulcers that have not healed within 30 days of occurrence.

Electrical stimulation will not be covered as an initial treatment modality.

Electrical stimulation will be covered only after appropriate standard wound therapy has been tried for at least 30-days and there are no measurable signs of healing. This 30-day period can begin while the wound is acute.

Measurable signs of improved healing include a decrease in wound size, either surface area or volume, decrease in amount of exudates and decrease in amount of necrotic tissue. Standard wound care includes: optimization of nutritional status; debridement by any means to remove devitalized tissue; maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings; and necessary treatment to resolve any infection that may be present.

Continued treatment with electrical

stimulation is not covered if measurable signs

of healing have not been demonstrated within

any 30-day period of treatment.

Electrical stimulation must be discontinued

when the wound demonstrates 100 per-cent

epithelialzed wound bed.

This service can only be covered when

performed by a physician, physical therapist,

or incident to a physician service.

Based on the results from animal studies, HVPC may have an effect upon acute edema FORMATION but the effect is short-lived (several hours); therefore, treatment is recommended for 30 minutes every 4 hours for the period of time that bleeding/swelling is expected to occur. This treatment duration and frequency fits well with the RICE protocol but may often be too frequent for an individual needing/trying to function (work or school). A portable HVPC unit is essential (and available)

This treatment is indicated for acute

trauma (sprain, strain, contusion) or post-

surgery. The situation must be an ACUTE

TRAUMATIC CONDITION where

bleeding, swelling & inflammation are

actively developing. The underlying

physiological effect is largely unknown but

studies often point toward an effect upon

capillary permeability - related to

histamine release.

STAGE Rx CURRENT Polarity FREQ RESPONSE TIME

ACUTE Control of

Formation

HVPC (--) 120 PPS SUBMOTOR 30 Min/

4 HRS

during

acute

stage

SUBACUTE

I CHRONIC

Reduction HVPC

BIPHASIC

RUSSIAN

N/A Varies:

need ms.

pump

MOTOR 20 min

daily

It is basically a variation of sinusoidal currents. Sinusoidal currents are alternating low frequency currents, having frequency of 50 Hz and pulse duration of 10 msec, providing 100 stimuli / sec.

: There are five different currents

available for didynamic therapy. 1. DF (Fixed di-phase):Full-wave rectified alternating current,

with a frequency of 50 Hz. 2. MF (Fixed mono-phase):Half-wave rectified alternating current,

with a frequency of 50 Hz. 3. CP (Short periods):

I-sec DF I-sec MF I-sec DF

Equal phases of DF and MF, alternating without interval pauses.

4. LP (Long periods):10-sec MF 5-sec DF 10-sec MF

It includes 10-sec phase of MF, followed by 5-sec phase of DF, in which peak intensity is varied with a frequency to rise and then fall.

5. RS (Syncopal Rhythm): It comprises 1-sec phase of MF,

followed by a 1-sec rest phase.

Physical properties

* Pain masking (increase of the stimulation threshold):By DF current, stimulation of the sensory nerves may not always cause excitation but it can be altered.

* Vasodilatation and hyperemia: Due to release of histamine in the tissues. The same can occur in deeper structures by reflex activity.

* Muscle fibers stimulation: Didynamic current stimulates the muscle fibers, causing muscle contraction. CP and LP currents stimulate increase blood flow to the muscle and reduce edema.

* Stimulation of vibration sense: This leads to central masking of pain sensation.

Didynamic stimulation causes relief of pain and edema in the following conditions:

Soft tissue injury (sprains, strain, contusion and epicondylitis).

Joint disorders (post-immobilization and arthritis).

Circulatory disorders (Raynaud's disease and migraine).

Peripheral nerve disorders (neuralgia and sciatic neuritis).

* Open skin: The current tends to concentrate at this point; small broken areas can be insulated by Vaseline.

* Bony areas: It may produce burn.* Loss of sensation: It can produce burn.* Skin lesions: Eczema fungi can be irritated and

made worse.* Infections: It may cause spreading of infection.* Thrombosis.* Cardiac pace makers.* Superficial metal.

* Intensity: It should be increased gradually until definite vibration or prickling sensation occurs.

* Duration: Not more than 12 minutes; each type for 3 minutes.

* Frequency: Daily or every other day for 12 sessions.

DF: It is used for the initial treatment and before application of other currents. The patient feels a prickling sensation, which subsides after a short time.

- MF: The patient feels a strong vibration for longer time than the sensation of DF. It is used for treatment of pain without muscle spasm.

- CP: In DF phase, there are fine tremors in MF phase (strong and constant vibration). There are rhythmic contractions, being used for treatment of traumatic pain.

- LP: It has a long-lasting analgesic effect. It is used with combination of CP in treatment of neuralgia.

- RS: It can be used for faradic stimulation of the muscle and as a test for motor nerve excitability.

“low-intensity direct current that delivers monophasicor biphasic pulsed microamperage currents across the intact surface of the skin’’

MET uses currents that are 1/1000th of an ampere smaller than those delivered by standard TENS devices (milliamperes)

Microcurrent electrical nerve stimulationMicroamperage stimulationLow-intensity direct current and Pulsed low intensity direct current

Microcurrenteffect600 HzSkinSurface500 HzSkin subSurface300 HzLymphatic

stimulation20 HzCirculation10 HzFacial muscles0.8 HzDeep facial Waveform shapeMicro-

current effectSineSuperficialSquarePumpingRectangularLiftingSawtooth

(Ramp)Longer lifting

Specifications

Channels :Dual

Power Source :9V alkaline

battery

Output Voltage :12 volts

Timer :20, 40 min and

constant

Frequency :0.3, 8 and 80Hz

Alleviation of

Pain

Inflammation

Spasm

Promotion of

Healing

Osteoarthrotis

Osteoporosis

Sports injuries

Fractures

Wounds and

Ulcers

Sinusoidal currents are evenly alternating

sine wave currents of 50Hz, the form of

the UK mains current (see Fig. 3.4). This

gives 100 pulses or phases in each

second of 10 ms each, 50 in one direction

and 50 in the other. It can be produced

from the mains by reducing the voltage to

60 or 80 V with a step-down

transformer.

Indicated to introduce ions into the body using direct current

Advantages are it’s painless, sterile, noninvasive

Phonophoresisdelivers whole molecules across the skin into the body.

Iontophoresis delivers ions into the tissues.

Both are noninvasive means to delivers chemicals to the body

Negatively charged electrons are repelled from the cathode. Thus negatively charged electrons move toward the positive pole where they create an acid reaction.

Positively charged ions are attracted to the negative electrode creating an alkaline reaction at the cathode

Positively charged ions are driven into tissues from the positive pole

Negatively charged ions are driven into tissues from the negative pole

Therefore you must know the polarity and match it with the appropriate electrode

Ion flow is dependent upon:• Tissue impedance

• Strength of current field

• Ion migration is caused by the potential difference in current density between the active and dispersive electrodes

Adjusted by: 1. Intensity

adjustments 2. Changing the size

of the electrode

Directly related to:

• 1. Intensity of the

current (density at the

active electrode)

• 2. Duration of current

flow

• 3. Concentration of

ions in solution

Low amp more effective than higher current intensities

Higher intensities reduce effective penetration to tissues

Usually between 3-5 ma Increase the intensity

slowly- WANT pt to Report “Prickling” or “Tingling”

Pt reports of Burning or Pain mean STOP!!

Slowly decrease intensity to 0 when terminating treatment

Remove electrodes Max current intensity may

be determined by the size of the active electrode.

Current amplitude is set so that the current density falls between .1-.5ma/cm2

10-20 minutes Average 15 Check skin every 3-5

minutes

Only use compounds soluble in both fat and water Penetration <1mm

Heavy metals tend to become insoluble precipitates inhibiting their penetration

Negative ions at anode produce acidic reaction via formation of HCL.

Pos ions at the cathode produce alkaline reactions, forming sodium hydroxide

Table 7-1. Recommended Ions for Use By Therapists42

POSITIVEAntibiotics, gentamycin sulfate (+), 8 mg/mL, for suppurative ear chondritis.Calcium (+), from calcium chloride, 2% aqueous solution, believed to stabilize the

irritability threshold in either direction, as dictated by the physiologic needs of the tissues. Effective with spasmodic conditions, tics, and "snapping fingers" (joints).

Copper (+), from a 2% aqueous solution of copper sulfate crystals; fungicide, astringent, useful with intranasal conditions, e.g., allergic rhinitis or "hay fever," sinusitis, and also dermatophytosis or "athlete's foot."

Hyaluronidase (+), from Wydase crystals in aqueous solution as directed; for localized edema.

Lidocaine (+), from XYLOCAINE 5% ointment, anesthetic/analgesic, especially with acute inflammatory conditions (e.g., bursitis, tendinitis, tic doloreux, and TMJ pain).

Lithium (+), from lithium chloride or carbonate, 2% aqueous solution, effective as an exchange ion with gouty tophi and hyperuricemia.

Magnesium (+), from magnesium sulfate ("Epsom Salts"), 2% aqueous solution, an excellent muscle relaxant, good vasodilator, and mild analgesic.

Mecholyl (+), familiar derivative of acetylcholine, 0.25% ointment, is a powerful vasodilator, good muscle relaxant, and analgesic. Used with discogenic low back radiculopathies and sympathetic reflex dystrophy.

Priscoline (+), from benzazoline hydrochloride, 2% aqueous solution, reported effective with indolent ulcers.

Zinc (+), from zinc oxide ointment, 20%, a trace element necessary for healing, especially effective with open lesions and ulcerations.

NEGATIVEAcetate (-), from acetic acid, 2% aqueous solution; dramatically

effective as a sclerolytic exchange ion with calcific deposits.Chlorine (-), from sodium chloride, 2% aqueous solution, good

sclerolytic agent. Useful with scar tissue, keloids, and burns.Citrate (-), from potassium citrate, 2% aqueous solution, reported

effective in rheumatoid arthritis.Dexamethasone (-), from Decadron, used for treating musculoskeletal

inflammatory conditions.Iodine (-), from "Iodex" ointment, 4.7%, an excellent sclerolytic agent,

as well as bacteriocidal, fair vasodilator. Used successfully with adhesive capsulitis ("frozen shoulder"), scars, etc.

Salicylate (-), from "Iodex with methyl salicylate," 4.8% ointment, a general decongestant, sclerolytic, and anti-inflammatory agent. If desired without the iodine, may be obtained from MYOFLEX ointment (trolamine salicylate 10%) or a 2% aqueous solution of sodium salicylate powder. Used successfully with frozen shoulder, scar tissue, warts, and other adhesive or edematous conditions.

EITHERRinger's solution(+/-), with alternating polarity for open decubitus

lesions.Tap water (+/-), usually administered with alternating polarity and

sometimes with glycopyrronium bromide in hyperhidrosis.

Analgesia

Scar modification

Wound healing

Edema

Burns

RSD

Inflammatory MS

conditions

CA++ deposits

Hyperhidrosis

M spasm

Fungi open skin

lesions

Herpes

Gout

Skin sensitivity reax

Sensitivity to agent

Gastritis/ulcer-

cortisone

Asthma-mecholyl

Sensitivity to metal

Sensitivity to seafood-

iodine

Recent scars in

treatment area

Metal implants close

to skin

Acute injury where

there is still bleeding

PPM