Transcript ELECTRICAL STIMULATION DEVICES

ELECTRICAL STIMULATION
DEVICES
pages 73 - 117
DR. GRANT
CLASSIFICATION
 Electrical
stimulation devices can be
classified in several ways.
 One method is based on the type of
current that is used (AC or DC)
 Secondly, the amount of voltage that
may be produced (Low voltage or High
voltage)
 Thirdly, by reference to some unique
aspect of the current that is used (IF,
Russian Stim.)
INTRODUCTION TO
ELECTROTHERAPY
Electrotherapy
- in particular interferential therapy - has proven
to be one of the more successful
therapies.
Such popularity is for good reason.
Practitioners using electrotherapy
devices have experienced
favorable results in relieving pain.
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INTRODUCTION TO
ELECTROTHERAPY
The
degree of success achieved in
adding electrotherapy to a practice
is measured in terms of how quickly
and efficiently it can be learned and
implemented.
Electrotherapy devices are now
“user friendly”
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INTRODUCTION TO
ELECTROTHERAPY
Interferential
quadrapolar,
premodulated quadrapolar
premodulated (bipolar), and
Russian and biphasic stimulation ,
conveniently and economically can
be housed in one easy-to -use unit.
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INTERFERENTIAL THERAPY
The
name Interferential therapy
stems from the concept of two
currents interfering with each other
This becomes readily apparent
when one views the four electrodes
(quadrapolar) that are necessary to
produce the standard interferential
effect in a patient
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INTERFERENTIAL THERAPY
I.F.
is one of a number of electrical
stimulation techniques used in
modern physiotherapy.
The common feature of all
modalities is the ability to facilitate
healing in damaged tissues
However, I.F. has a number of
advantages: comfortable and
penetrates deeper
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INTERFERENTIAL THERAPY
The
beat frequency in Hz is simply
the difference in frequency between
the two medium frequency
currents.
This “beating” is the actual
“interferential effect”
The beat frequency relates solely to
the number of times per second the
intensity increases and decreases.
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INTERFERENTIAL THERAPY
PRE-MODULATED BIPOLAR
It
is possible to deliver I.F. currents
to a patient using two, instead of
the conventional four electrodes.
In this system, the two currents are
“mixed” in the machine and
delivered to the patient via two
electrodes (premodulated).
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INTERFERENTIAL THERAPY
PRE-MODULATED BIPOLAR
Premodulated
bipolar therapy helps
to reduce pain and increase range
of motion.
In some cases, it provides an
effective substitute for quadrapolar
treatment especially when treating
small areas of the body where four
electrodes cannot be placed.
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INTERFERENTIAL THERAPY
PRE-MODULATED BIPOLAR
Premodulated
bipolar therapy
utilizes one output jack, and
produces a composite wave form
identical to the interferential
current, while using only two
electrodes.
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INTERFERENTIAL THERAPY
The
average treatment time for
most applications being 20 to 30
minutes.
On the first treatment session, it is
wiser to halve this, in order to
ensure that there is no abnormal
response from the patient.
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INTERFERENTIAL THERAPY
TREATMENT DURATION
There
has never been a set
number of treatment sessions for
any particular clinical problem since
all patients and problems are
different.
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INTERFERENTIAL THERAPY
TREATMENT DURATION
However,
if the overall treatment
program has been carefully
designed and delivered , then good
results should be expected fairly
quickly.
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INTERFERENTIAL THERAPY
TREATMENT DURATION
I.F.
like other forms of
electrotherapy, are meant to be
used as an adjunct to other forms
of treatment.
In most cases, six to ten sessions
of I.F., together with other
measures should produce
considerable improvement in the
patient.
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INTERFERENTIAL THERAPY
There
is no point in continuing with
a technique which appears to be
having no effect.
If the patient’s condition is
unchanged after one or two
treatments, then the situation
needs re-assessing.
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INTERFERENTIAL THERAPY
Assuming
that the machine is
working correctly and is applied
properly, then poor results should
indicate possible change in
electrode position and/or a change
in frequency/intensity.
The physiological effect of I.F.
depends on the frequency of the
current.
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INTERFERENTIAL THERAPY
PHYSIOLOGICAL
OBJECTIVES
Pain
relief both acute and chronic
Reduction of edema
re-education and strengthening of
muscle.
Stimulation and improvement of
circulation
General facilitation of healing
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INTERFERENTIAL THERAPY
I.F.
can and should be combined
with other modalities except ice
(over the electrodes) and
diathermy.
Combining treatments implies
giving two different but
complimentary treatments at
different times or in some instances
at the same time (moist heat)
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INTERFERENTIAL THERAPY
The
generally accepted range of
frequency is 0 to 150 Hz, with a low
range from 0 to 10 Hz, commonly
accepted as the appropriate
treatment for increasing local blood
circulation; and a high range from
80 to 150 Hz which is used for pain
relief.
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INTERFERENTIAL THERAPY
CONTRAINDICATIONS
Pacemakers
Thrombosis
Cardiac
Conditions
Bacterial Infections
Malignancy
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INTERFERENTIAL THERAPY
WARNINGS
Pregnancy
Implants
of any electrical nature
Transcerebrally
Skin diseases
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INTERFERENTIAL THERAPY
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INTERFERENTIAL THERAPY
INTERFERENTIAL THERAPY
INTERFERENTIAL THERAPY
INTERFERENTIAL THERAPY
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Questions regarding Interferential
therapy?
RUSSIAN STIMULATION
DR. GRANT
Pain Alliance Institute
RUSSIAN STIMULATION
Dr.
Y.M. Kots, a Russian physiatrist,
has been credited with the
development of Russian Stim
during the late 1960’s.
Presented seminars in the U.S. on
the use of EMS to augment
strength gain
RUSSIAN STIMULATION
The stimulators developed in the
U.S. and Canada after Dr. Kots
presentations were termed Russian
current generators.
These stimulators deliver a medium
frequency (2,000 to 10,000 Hz)
The peak current intensity
stimulates muscle very well and is
comfortable.
RUSSIAN STIMULATION
 They
presently deliver a medium
frequency, polyphasic AC wave form.
 The pulse can be varied from 50 to 250
m.sec.; The phase duration will be 1/2
the pulse duration.
 As the pulse frequency increases, the
phase duration decreases.
RUSSIAN STIMULATION
 Because
it is a fast oscillating AC
current, as soon as the nerve
repolarizes it is stimulated again,
producing a current that will maximally
summate muscle contraction.
 The frequency (bursts per second) is
also a variable that can be controlled.
RUSSIAN STIMULATION
AC
medium frequency 2500 Hz
Primary purpose is for muscle
rehab/re-education.
Also used for reducing muscle
spasms
RUSSIAN STIMULATION
PHYSIOLOGICAL EFFECTS
Muscle
strengthening and reeducation
Decrease edema
Increase blood flow
Reduces muscle spasm
 This
would make the muscle respond
with a twitch rather than a gradually
increasing mechanical contraction.
RUSSIAN STIMULATION
PHYSIOLOGICAL EFFECTS
 Gradually
increasing the number of
bursts interrupts the mechanical
relaxation cycle of the muscle and
causes more shortening to take place .
RUSSIAN STIMULATION
The initial uses of Russian
Stimulation in the U.S. were for
rehabilitation following surgical
procedures such as ACL repair.
Strengthening of the quadriceps
muscle to correct atrophy of disuse
has become a standard, effective
treatment procedure.
RUSSIAN STIMULATION
INDICATIONS
Chronic
back pain
Post-injury muscle atrophy and/or
wasting
Post-casting
Muscle spasms
RUSSIAN STIMULATION
CONTRAINDICATIONS
Pacemakers
Malignant
lesions
Upper thorax (anterior)
Pregnancy
RUSSIAN STIMULATION
APPLICATION
10/50
pre-set
Start with low on times and long off
times with long ramp times
As strength begins to return,
increase on times and decrease off
times with shorter ramp
RUSSIAN STIMULATION
PAD PLACEMENT
Bipolar
technique
Origins and insertions and/or until
you see a muscle contraction that
is tolerable to the patient.
RUSSIAN STIMULATION
SUMMARY
When
an electrical stimulation is
applied to muscle or nerve tissue,
the result will be tissue membrane
depolarization, provided that the
current has the appropriate
intensity, duration, and waveform to
reach the tissue’s excitability
threshold.
RUSSIAN STIMULATION
SUMMARY
Muscle
contraction will change
according to changes in current.
As the frequency of the electrical
stimulus increases, the muscle will
develop more tension as a result of
the summation of the contraction of
the muscle fiber through
progressive mechanical shortening.
RUSSIAN STIMULATION
SUMMARY
Increases
in intensity spreads the
current over a larger area and
increases the number of motor
units activated by the current.
Increases in the duration of the
current also will cause more motor
units to be activated.
RUSSIAN STIMULATION
SUMMARY
Electrically stimulated muscle
contractions are used clinically to:
1 . Help with muscle re-education
2 . Muscle contraction for muscle
pumping action
3 . Reduction of swelling
4 . Prevention or retardation of atrophy
RUSSIAN STIMULATION
SUMMARY
5 . Muscle strengthening
6 . Increasing range of motion in tight
joints.
RUSSIAN STIMULATION
SUMMARY
It
does appear that the intensity of
contraction is positively correlated
to strength gains.
The stronger the contraction, the
greater the gain.
RUSSIAN STIMULATION
10/10 PRE-SET
Physiological
effects are as follows:
1.Decrease edema via pumping
effect
2.Break spasms by fatigue of
muscles
3.Increase blood flow
10/10 PRE-SET
INDICATIONS
Muscle
spasms
Edematous situations
10/10 PRE-SET
PAD PLACEMENT
Bipolar
technique
Origins and insertions and/or you
see a muscle contraction that is
tolerable to the patient.
Polarity not important
RUSSIAN STIMULATION
RUSSIAN STIMULATION
Questions regarding Russian
stimulation therapy?
BIPHASIC STIMULATION
COURSE # 6106
DR. GRANT
BIPHASIC THERAPY
 In
Biphasic stimulation mode the ouput
of the modality allows you to choose a
muscle contraction/relaxation cycle that
is most suited for the individual patient
and for the desired treatment.
 When the cycle is chosen, each musclestimulating burst is followed by a
relaxation (rest) cycle.
BIPHASIC THERAPY
 There
are 3 modes of treatment in
Biphasic stimulation:
1 . Normal
2 . Reciprocal
3 . Co-Contraction
 You
will need to decide which mode is
to be used and attach the appropriate
number of leads needed before setting
up the treatment.
BIPHASIC THERAPY
 Normal:
Use one channel with one lead
wire (two electrodes)
 The contraction/relaxation cycle is
selected from an option list of 10/10,
10/30, 10/50 and continuous (there is
no rest cycle with continuous).
 The continuous cycle is not
recommended for EMS.
BIPHASIC THERAPY
 Co-Contraction:
Use two channels and
two lead wires (four electrodes).
 Each pair of electrodes is placed over a
different muscle group.
 This treatment fires the two muscle
groups simultaneously - Contraction
and rest cycles for both treatment areas
occur at the same time. Two channels
are required (1 and 2)
BIPHASIC THERAPY
 Reciprocal:
Use two channels and two
lead wires (four electrodes) for this
treatment.
 The reciprocal muscle stimulation fires
two muscle groups (such as
flexors/extensors) one after the other.
 Example: 10/30 setting, the modality
would deliver stimulation for 10 seconds
to the first muscle followed by 10
seconds of stimulation to the reciprocal
muscle.
BIPHASIC THERAPY
 Press
the Biphasic key
 Choose the treatment mode
 Choose the contraction/rest times
 Choose the ramp setting
 Raise the intensity to the desired level
 For co-contraction or reciprocal
treatments, choose the second channel
and set the intensity for this channel
 Press start
BIPHASIC THERAPY
 When
choosing the Biphasic function,
the default settings are automatically
selected:
1 . Normal treatment mode
2 . 10/30 contraction/rest times
3 . Ramp up and down time : .5 sec.
 Increase
the intensity to the patients
tolerance
 Press start
BIPHASIC THERAPY
CAUTION
 NEVER
TURN THE POWER ON OR
OFF WHILE THE UNIT IS
CONNECTED TO THE PATIENT
BIPHASIC STIMULATION
Questions regarding Biphasic
Therapy?
HIGH VOLT THERAPY
Course #6106
DR. GRANT
79
Pain Alliance Institute
HIGH VOLTAGE THERAPY
HV
is a unidirectional, pulsed
current of up to 500 V force and
average current of 1.0 - 1.5 mA.
Pulsed duration is generally
between 20 and 200 microsec.
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HIGH VOLTAGE THERAPY
In
the past, it has been customary
to refer to these stimulators as
“high voltage galvanic stimulators”
This inaccurate use of the term
“galvanic” has led many to claim a
significant polarizing effect for HVG
machines.
HIGH VOLTAGE THERAPY
Although
these stimulators use DC,
there is only a minimal polarizing
effect and they are not capable of
iontophoresis.
HIGH VOLTAGE THERAPY
The
term galvanic refers to a
continuous, nonpulsed current that
is used for iontophoresis
HIGH VOLTAGE THERAPY
The
traditional term “high voltage
galvanism” is somewhat
misleading, as clinicians tend to
confuse and /or equate the effects
of HVT with low-voltage galvanism.
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HIGH VOLTAGE THERAPY
Manufactures
of HVT equipment
offer guidelines for the choice of
polarity in particular situations, but
research has not yet substantiated
these guidelines.
Polarity appears relatively
unimportant in many
circumstances.
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HIGH VOLTAGE THERAPY
In
contrast to low voltage, high
voltage offers a more comfortable
current that is safer to use and
more universal in its application.
Because of its high peak current
and short pulse duration,
penetration is deeper, with less
sensory disturbance and less heat
production.
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HIGH VOLTAGE THERAPY
EFFECTS
Analgesia
Edema absorption
 Muscle contraction
Increased peripheral circulation

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HIGH VOLTAGE THERAPY
INDICATIONS
Soft
tissue injuries
Sciatica
Arthritic conditions
Nonsystemic edema
Muscle spasm, muscle reeducation
 Trigger Point therapy
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HIGH VOLTAGE THERAPY
CONTRAINDICATIONS
Malignancy
Patients
with pacemakers
Pregnancy
Over open wounds
Transcerebrally
Cardiac conditions
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HIGH VOLTAGE THERAPY
If
treating trigger points,
acupuncture points, or motor
points, use a probe instead of
active pads.
Turn the intensity to the level of
mild sensory stimulation and probe
the area to locate the exact location
to be stimulated.
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HIGH VOLTAGE THERAPY
Continue
to increase the intensity
until the desired effect is achieved.
Trigger points will usually become
less painful in 15 - 30 seconds.
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HIGH VOLTAGE THERAPY
APPLICATION
The
treatment setup utilizes a
double-output lead with two
electrodes; an active and a
dispersive electrode (monopolar
technique).
The size of the dispersive electrode
is recommended to be double the
area of the active electrode.
HIGH VOLTAGE THERAPY
APPLICATION
If
desired, the active output of the
lead may be bifurcated to attach
additional active electrodes;
however, the combined total of the
active electrodes must be less than
the area of the single dispersive
electrode.
HIGH VOLTAGE THERAPY
APPLICATION
 In
the output labeled “HV” connect one
lead with two output connections.
 It is best to use a lead that is marked to
show the polarity of the output end.
 The active electrode is connected to the
lead output that is marked positive
 The dispersive electrode is connected
to the lead output that is marked
negative.
HIGH VOLTAGE THERAPY
APPLICATION
 During
treatment current flows in one
direction between the electrodes.
 Polarity of the treatment is not
controlled by the polarity of the lead
wires, but is controlled by the polarity
selection you make on the front panel of
the unit.
HIGH VOLTAGE THERAPY
APPLICATION
 Changing
the polarity in the treatment
parameters has the effect of reversing
the direction of the current flow between
electrodes.
 It is important to attach the active
electrode to the positive output of the
lead wire to ensure the polarity you
have selected is delivered.
HIGH VOLT APPLICATION

.

.
Press HV and choose polarity
The available options include
positive (+) , negative (-), or both.
When both are selected, the unit
alternates between the two,
delivering each polarity for
approximately 30 seconds.
Choose the contraction/rest cycle
times.
. HIGH


.
.

.

.
VOLT APPLICATION
Choose the Ramp setting
Choose High or Low pulse rate
range. High is for acute and Low is
for chronic
Raise the intensity to the patients
tolerance.
Press Start
.
HIGH VOLT APPLICATION
 Default
settings are as follows:
 . 10/30 contraction/rest times
2 . Treatment time - 10 minutes
3 . Ramp up and down time - .5 sec.
4 . Pulse rate: High Range - 80-120 Hz, Low
Range - 1-10 Hz, available range - 1-200
Hz
5 . Raise intensity level to patients tolerance
6 . Press start
HIGH VOLT THERAPY
HIGH VOLT THERAPY
Questions regarding High Volt
therapy?
LOW VOLTAGE
STIMULATORS
Dr. Grant
LOW VOLTAGE THERAPY
Low
frequency alternating currents
are utilized because of the
continued need for electrical
stimulation of atrophied muscle,
especially for patients with CNS
lesions.
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LOW VOLTAGE THERAPY
 When
low volt AC current of sufficient
intensity is applied to the muscle, a
contraction will be noted as long as the
current is allowed to flow.
 The muscle will contract in time with the
frequency(or pulses per second). At one
pulse per second, the muscle will
contract and relax once per second.
LOW VOLTAGE THERAPY
 As
the frequency is increased, the
muscle pumps faster until you reach a
stage (approximately 35 pps) where the
muscle is incapable of relaxing before
the next electrical pulse arrives ( a
“tetanized” contraction).
 A steady contraction is noted .
 As you progress beyond 35 pps, the
contraction becomes stronger.
LOW VOLTAGE THERAPY
EFFECTS
Contraction
of enervated muscle
Pain relief
Edema reduction

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LOW VOLTAGE THERAPY
INDICATIONS
Stimulation
of weak and/or
atrophied muscles
Nonsystemic edema
pain syndromes
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LOW VOLTAGE THERAPY
CONTRAINDICATIONS
Through
the brain, heart or eyes
Over bony prominences
Fractures
Skin lesions
Malignancy
Anesthetic areas
Over a gravid uterus
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LOW VOLTAGE THERAPY
Application
Place
pads firmly on treating parts;
can use hot packs, for combination
therapy.
Quadrapolar or bipolar technique
may be used.
If unequal sized pads, (monopolar
technique) is used, the smaller pad
will produce a greater effect.
113
LOW VOLTAGE THERAPY
APPLICATION
A probe
may be used for specific
stimulation of motor points.
Set mode to: Pulse, if a gentle
treatment is desired, to avoid
further trauma or to disperse fluid.
Set mode to: Surge, if a series of
muscle contractions is desired
(e.g.., for muscle re-education)
114
LOW VOLTAGE THERAPY
APPLICATION
Set
mode to: Tetanize, if a tetanic
contraction is desired to fatigue the
muscle (e.g.., for muscle spasm or
muscle tension)
Choose the pulse width, “on ramp”
time, and/or “off ramp” time.
Set the timer to desired time
115
LOW VOLTAGE THERAPY
APPLICATION
Increase
the intensity slowly to
patient tolerance or until the
desired muscle contraction is
achieved.
Treatment duration depends on the
effect desired and the integrity of
the muscle being stimulated
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LOW VOLTAGE THERAPY
APPLICATION
Dr.
Kots of the Soviet Union has
suggested the following times:
To increase circulation: 2 sec on, 2
sec off
To reduce spasm and pain: 12 sec
on, 8 sec off
For strength endurance, and
velocity: 10 sec. on, 50 sec. off
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Questions regarding Low Voltage
therapy?
IONTOPHORESIS
Dr. Grant
IONTOPHORESIS
Iontophoresis
is a therapeutic
technique that involves the
introduction of ions into the body
tissues by means of a direct
electrical current.
The manner in which ions move in
solution forms the basis for
iontophoresis.
IONTOPHORESIS
Positively
charged ions are driven
into the tissues from the positive
pole, and negatively charged ions
are introduced by the negative
pole.
The force that acts to move ions
through the tissues is determined
by both the strength of the electrical
field and the electrical impedance
of tissues to current flow.
IONTOPHORESIS
The
quantity of ions transferred into
the tissues through iontophoresis is
determined by the intensity of the
current or current density at the
active electrode, the duration of the
current flow, and the concentration
of ions in solution.
IONTOPHORESIS
Continuous
direct current must be
used for iontophoresis, thus
ensuring the unidirectional flow of
ions that cannot be accomplished
using a bi-directional or alternating
current.
Electrodes may be either borrowed
from other ES or commercially
manufactured ready-to-use
disposable electrodes.
IONTOPHORESIS
 Iontophoresis
is used to treat
Inflammatory musculoskeletal
conditions, for analgesic effects, scar
modification, wound healing, and in
treating edema, and calcium deposits.
 Probably the single most common
problem associated with iontophoresis
is a chemical burn that usually occurs
as a result of the DC itself and not
because of the ion being used in
treatment
IONTOPHORESIS
 Neither
high-voltage direct current or
interferential currents may be used for
iontophoresis since the current is
interrupted and the current duration is
too short to produce significant ion
movement.
 Recommended current amplitudes used
for iontophoresis range between 3 and
5 mamp.
IONTOPHORESIS
 Recommended
treatment durations
range between 10 and 20 minutes, with
15 minutes being average.
 During this 15 minute treatment, the
patient should be comfortable with no
reported visible signs of pain or burning.
 The doctor should check the patient’s
skin every 3-5 minutes during treatment,
looking for signs of skin irritation.
IONTOPHORESIS
 Since
skin impedance usually
decreases during the treatment, it may
be necessary to decrease current
intensity to avoid pain or burning.
IONTOPHORESIS
ELECTRODES
 The
commercially produced electrodes
are sold with most iontophoresis
systems.
 These electrodes have a small
chamber, into which the ionized solution
may be injected, that is, covered by
some type of semipermeable
membrane.
 The electrode self-adheres to the skin.
IONTOPHORESIS
ELECTRODES
 This
type of electrodes has eliminated
the “mess and hassles” that have been
associated with electrode preparation
for iontophoresis in the past.
 Once the electrode has been prepared.
It then becomes the active electrode,
and the lead wire to the generator is
attached such that the polarity of the
wire is the same as the polarity of the
ion in solution.
IONTOPHORESIS
ELECTRODES
 A second
electrode, the dispersive
electrode, is prepared with water, gel, or
some other conductive material as
recommended by the manufacture.
 Both electrodes must be securely
attached to the skin such that uniform
skin contact and pressure is maintained
under both electrodes to minimize the
risk of burns.
IONTOPHORESIS
ELECTRODES
 The
size and shape of the electrodes
can cause a variation in current density
and affects the size of the area treated.
 Smaller electrodes have a higher
current density and should be used to
treat a specific lesion.
 Larger electrodes should be used when
the target treatment area is not welldefined.
IONTOPHORESIS
ELECTRODES
 Recommendations
for spacing between
the active and dispersive electrodes
seem to be variable.
 They should be separated by at least
the diameter of the active electrode.
 One source has recommended spacing
them at least 18 inches apart.
IONTOPHORESIS
ELECTRODES
 As
spacing between the electrodes
increases, the current density in the
superficial tissues will decrease,
perhaps minimizing the potential for
burns.
CLINICAL APPLICATIONS
FOR IONTOPHORESIS
 Clinically,
iontophoresis is most often
used in the treatment of inflammatory
musculoskeletal conditions.
 It may be used for analgesia, scar
modification, wound healing, and in
treating edema, calcium deposits, and
hyperhidrosis.
IONTOPHORESIS
Conditions Treated
Spasm:
Calcium, magnesium
Inflammation: Hydrocortisone,
salicylate dexamethosone.
Analgesia: Lidocaine, magnesium
Edema: Magnesium, mecholyl,
hyaluronidase, salicylate
Ischemia: Magnesium, mecholyl,
iodine
Fungi: Copper
INDICATIONS
CONTRAINDICATIONS
IONTOPHORESIS
Questions regarding
Iontophoresis?
TENS
DR. GRANT
140
Pain Alliance Institute
TENS
TENS
should apply to any form of
electrical stimulation that is applied
via surface electrodes.
The term has been used for small
portable stimulators that can be
attached to the belt or clothing and
used for various time periods for
the relief of pain.
141
TENS
In
general the primary effect of
TENS is the relief of pain.
Many health practitioners are
finding TENS to be an effective,
safe, noninvasive, and cost
effective method of treating acute,
chronic and psychogenic pain of
innumerable origins.
142
TENS
 There
are two major theories of pain
control, the mechanisms of which are
considered to be operative when using
TENS: gate control and opiate-mediated
control.
TENS
 According
to the opiate-mediated theory
of pain control, endorphins are released
in the body and bind to specific receptor
sites in the CNS and PNS to decrease
pain perception and nociceptive
responses.
TENS
 ES
has been shown to increase the
levels of endorphins circulating in the
cerebrospinal fluid (CSF) of patients
with various neurological disorders, and
pain perception in these patients is
reduced with ES.
 ES controls pain by inducing the release
of endogenous opiates.
TENS
 Other
proposed mechanisms of pain
control include enhancement of tissue
healing, modification of the flow of
energy in acupuncture meridians, and
placebo effects.
TENS
INDICATIONS
Chronic
pain
Acute pain
Intractable pain (TENS can provide
adequate relief of pain secondary
to malignancy). Results are best
with trunk and extremity pain and
worst with pelvic and perineal pain.
147
TENS
INDICATIONS
Rehabilitation:
The use of TENS for
the reduction of pain during
rehabilitation can increase
performance and shorten disability.
Care must be taken to not allow the
TENS to obliterate pain to the
extent that the patient loses
protective cues and overstresses
the part being rehabilitated.
148
TENS
CONTRAINDICATIONS
Pacemakers
Carotid
nerve stimulation
Laryngeal stimulation
During pregnancy
149
TENS TREATMENT
METHODS
 There
are several different methods for
delivering TENS for pain control.
 It may be necessary to try more than
one method, or a combination of
methods, with a given patient in order to
find the most effective intervention for
that individual.
TENS TREATMENT
METHODS
 The
methods include the following:
1 . Sub-sensory level stimulation (MENS)
2 . Sensory level stimulation (High TENS)
3 . Motor Level stimulation (Low TENS)
4 . Noxious level stimulation
Sub-sensory level stimulation
 Also
referred to as subliminal
stimulation or microcurrent electrical
nerve stimulation.
 Delivers current at intensities that are
below threshold for nerve
depolarization.
 The literature does not contain clear or
consistent methods of manipulating
parameters for pain control using this
type of stimulation.
SENSORY LEVEL
STIMULATION
 Is
commonly referred to as conventional
or highTENS
 This method of pain control is
considered to operate via the gate
control mechanism.
 It is most commonly used for controlling
pain during the acute stages of injury,
but it may also be effective in chronic
situations.
SENSORY LEVEL
STIMULATION
 The
onset of the decrease in the
nociceptive response is relatively quick,
generally within 5 minutes of initiating
the stimulation; however, the decrease
does not generally last beyond 1 hour
after the stimulation is stopped.
MOTOR LEVEL
STIMULATION
 Also
known as Low TENS or
acupuncture like TENS is thought to
operate via an opiate-mediated
mechanism involving the release of
endorphins, although there may be a
gating effect with motor-level TENS
because sensory level fibers are also
activated during treatment.
MOTOR LEVEL
STIMULATION
 Motor
level TENS is commonly used in
chronic presentations of pain.
 If sensory level TENS is ineffective in
chronic cases and the patient can
tolerate muscle contractions.
 The onset of of pain relief with this type
of treatment is not usually immediate,
requiring approximately 15-60 minutes
of stimulation.
MOTOR LEVEL
STIMULATION
 The
pain relief may last for hours or
more after stimulation ceases, which is
no longer expected with sensory level
TENS.
NOXIOUS LEVEL
STIMULATION
 Opiate
mediated
 Most commonly used for treatment of
patients with chronic pain when the two
previously methods of TENS have been
unsuccessful.
 Onset of pain relief is usually rapid
within seconds or minutes of ES
stimulation.
NOXIOUS LEVEL
STIMULATION
 The
duration of pain relief is thought to
be similar to that achieved with motor
level TENS.
 When applying noxious level
stimulation, the intent is to produce by
either sensory and or motor stimulation.
NOXIOUS LEVEL
STIMULATION
 A painful
response can be produced
without a muscle contraction if
electrodes are placed over an area that
does not have superficially located
motor nerve fibers.
TENS
ELECTRODE PLACEMENT
Electrode
placement is one of the
most critical factors for the success
of TENS
Directly over or around the painful
site
Over trigger points
161
TENS
ELECTRODE PLACEMENT
Over
acupuncture points
Within a specific dermatome
At the site of the corresponding
nerve root.
TENS
The
most significant complication of
TENS is local skin rashes produced
by the conduction gel or tape.
Electrodes should be removed
every day or two to clean the skin
and inspect the area.
163
ELECTRODES
Initially,
dry pads were provided
that required the use of gel.
This was messy, provided uneven
conductivity, and caused minor skin
burns at high currents.
At present, self-adhesive
electrodes are available that are
semi-disposable and generally
affordable.
ELECTRODES
Most
TENS devices recommend
carbon based electrodes.
In this day and age of concern over
deadly infectious diseases, it has
become common practice for
practitioners who use TENS
clinically to keep a separate set of
electrodes for the exclusive use of
each patient.
TENS
There
is no contraindications to 24
hour use of “high TENS”.
 “Low” TENS”, however, should be
used only 30 - 40 minutes at a time,
as “Low TENS” causes muscle
contraction and may cause
soreness if used for longer periods.
166
HiTENS
The
term TENS is often associated
with the application of a high
frequency, low-intensity current that
is directed at closing the pain gate.
This is sometimes referred to as
conventional TENS, classic TENS,
or High TENS.
HIGH TENS
This
particular form of TENS
typically uses a spike or
asymmetric rectangular wave with
a pulse width of less than 200
microseconds.
The frequency range varies
between 50 to 150 Hz and the
intensity is set at a mild sensory
level (gentle tingling).
HIGH TENS
The
stimulation is towards the large
superficial sensory fibers (A-beta)
This type of stimulation usually
provides a fairly rapid and
comfortable form of pain relief.
HIGH TENS
With
this type of application, the
onset of pain suppression usually
occurs within minutes and lasts for
approximately I hour after
stimulation.
HIGH TENS
Stimulation
times vary considerably
from patient to patient.
They may be as short as 15
minutes in some with no return of
pain. others, such as immediate
postsurgical patients, may find it
helpful to leave the TENS on for
hours at a time.
HIGH TENS
The
electrode type, quality, and
contact affect the level of comfort
and the effectiveness of the
procedure.
Electrode placement is important to
effect a positive response.
HIGH TENS
This
high frequency form of TENS
appears to work best when
electrodes surround the injured
area or are applied within the same
spinal segments as the pain
HIGH TENS
The
electrode position and intensity
should be adjusted so that tingling
can be felt throughout the area of
pain.
Electrode placement may need to
be altered several times to supply
adequate pain relief.
LOW TENS
This
form of TENS is intended to
produce analgesia by stimulating
the release of endorphins and
enkaphalins.
It is also referred to as
“acupuncture-like TENS” or “noninvasive electroacupuncture.”
It uses a high-intensity current and
a very low frequency (1-5 Hz)
LoTENS
It
appears that the higher the
intensity of the stimulation, the
greater the physiologic response.
Unlike other forms of ES, Low
TENS applications appear to be
frequency- dependent with little
room for variation.
LOW TENS
The
mechanism of action is via the
release of endorphins and
enkaphalins and because of the
half-life of endorphins, the relief
gained is typically longer lasting
than that found with conventional
TENS.
LOW TENS
The
time required to induce any
significant endorphin release is
between 20 and 45 minutes.
Low TENS application may provide
relief in some patients who are
resistant to conventional TENS.
BURST TENS
Burst
TENS consist of clusters of
high-frequency pulses or trains (70100 Hz) that are repeated at an
acupuncture frequency of 1 to 5 Hz.
The pulse width and amperage are
variable
The intensity is raised to a motor
level stimulus
BURST TENS
The
strength of the contraction
varies from barely perceptible to
strong rhythmic pulses.
As with Low TENS, the evidence
indicates that a stronger stimulation
produces better analgesia.
BURST TENS
The
mechanism of pain relief is
thought to be mixed with some
stimulation of superficial sensory
fibers and some endorphin
response.
The major advantage of this
modification over Low TENS is the
level of comfort afforded.
EFFECTIVENESS OF TENS
The
application of tens, particularly
in the chronic pain patient can be
enhanced or hindered by a variety
of factors. the following factors may
interfere with the successful
application of TENS.
FACTORS INTERFERING
WITH SUCCESS OF TENS
Medication
- particularly
corticosteroids, narcotics, and
diazepam, can deplete the body of
the chemicals necessary to control
pain.
FACTORS INTERFERING
WITH SUCCESS OF TENS
Prolonged
Pain and Stress Patients who have been in pain for
extended periods of time may fail to
respond to TENS for many reasons
including depression.
FACTORS INTERFERING
WITH SUCCESS OF TENS
Senility
- interferes with patient
understanding and the manual
dexterity necessary both to connect
electrodes and to control the TENS
devices.
FACTORS INTERFERING
WITH SUCCESS OF TENS
Patient
Understanding - As with
other forms of treatment,
compliance lessens if patients do
not understand the purpose of the
therapy, patients who are treated
with TENS, especially those who
use TENS units on an outpatient
basis, should be informed-
FACTORS INTERFERING
WITH SUCCESS OF TENS
-
regarding the purpose of
treatment, the application
techniques, electrode placement,
and equipment use.
Lack of co-operation - Patients who
are unwilling to learn how to use
the TENS unit properly or who are
noncompliant probably will not
respond well.
FACTORS INTERFERING
WITH SUCCESS OF TENS
Poor
Posture or Body Mechanics Many patients have pain due to
sustained postural stresses and/or
biomechanical dysfunction.
FACTORS INTERFERING
WITH SUCCESS OF TENS
It
is helpful to provide pain relief for
these patients, it is also important
to address such problems with
appropriate ergonomic
modifications and/or mechanical
therapies to eliminate or minimize
any continued aggravation.
FACTORS THAT ENHANCE
THE APPLICATION OF TENS
Wean
from Medications Appropriate communication with
medical providers is necessary to
determine the most effective painrelieving approach.
FACTORS THAT ENHANCE
THE APPLICATION OF TENS
Tryptophan A naturally
occurring
sedative, a precursor of serotonin,
aids in reducing pain and stress
levels. It is found in high quantities
in eggs, meat, poultry, and dairy
products.
FACTORS THAT ENHANCE
THE APPLICATION OF TENS
Stress
Reduction - Reducing and
eliminating stress helps improve
the efficacy of TENS.
One of the most useful stress
reduction techniques is relaxation
therapy
FACTORS THAT ENHANCE
THE APPLICATION OF TENS
With
practice, some patients may
find that they can control their pain
without the use of TENS or
pharmaceuticals.
FACTORS THAT ENHANCE
THE APPLICATION OF TENS
Current
modulations - Patients
rapidly accommodate or adapt to a
steady stimulus. When TENS is
used for a prolonged time it may be
helpful to modify the application
technique by using different forms
of TENS or by varying the current
parameters.
FACTORS THAT ENHANCE
THE APPLICATION OF TENS
Variable
Electrode Placements - As
with varying the parameters of
stimulation, it is often helpful to vary
the electrode placement , which not
only helps to reduce patient
accommodation, it also reduces the
likelihood of skin irritation.
FACTORS THAT ENHANCE
THE APPLICATION OF TENS
Patient
Willingness to Cooperate
and Experiment - Patient motivation
is always a major factor in
determining response to treatment,
whether it includes TENS,
manipulation, or exercise.
FACTORS THAT ENHANCE
THE APPLICATION OF TENS
Improvement
in Posture and Body
Mechanics - Improving the working
and living conditions of the patient
may prevent or reduce many of the
problems that produce and/or
aggravate painful conditions
TENS
LONG TERM EFFECT
As
with many other treatment
modalities, the long-term
effectiveness of TENS is to a large
extent determined by the manner in
which it is originally presented to
the patient.
TENS
LONG TERM EFFECT
The
success rate after several
months of use varies widely, with
some patients receiving significant
relief whereas others may hardly be
affected
TENS
LONG TERM EFFECT
The
success of TENS on a long
term basis is dependent upon the
willingness of both the doctor and
the patient to experiment with
different electrode placements,
frequencies, intensities, and forms.
Questions regarding TENS
application?
PAIN MANAGEMENT
DR. GRANT
PAIN MANAGEMENT
APPROACHES
 Pharmacological
approaches:
1 Systemic analgesics
2 Spinal analgesia
3 Local injections to painful structures
 Physical
agents
 Multidisciplinary pain treatment
programs
TREATMENT GOALS
 The
goals of treatment include:
1 . Eliminating the cause of pain
2 . Controlling the nociceptor input
3 . Reducing the degree of patient
impairment
BASIS OF GOALS
 These
approaches are based on our
current understanding of pain
transmission and control mechanisms
and may act by:
1 . Controlling inflammation
2 . Increasing binding to opiate receptors
3 . Modulating pain at the spinal cord level
 In
addition, some treatment approaches
also address the psychological and
social aspects of pain.
PAIN MGMT. APPROACHES
 Different
approaches are appropriate for
different situations and clinical
presentations and are frequently most
effective when used together.
ALLEVIATION OF PAIN
 The
primary intervention used to
alleviate pain is the administration of
pharmacological agents.
 Although pharmacological agents are
often effective for this purpose, they can
also produce a variety of adverse
effects.
ALLEVIATION OF PAIN
 The
use of physical agents , which also
effectively control pain in many cases
while producing fewer adverse effects,
may be more appropriate.
 Some patients, particularly those with
chronic pain, may need integrated
multidisciplinary treatment, which
includes psychological as well as
physiological therapies, in order to
achieve pain relief .
PHARMACOLOGICAL
APPROACHES
 Pharmacological
analgesic agents
control pain by modifying inflammatory
mediators at the periphery, altering pain
transmission from the periphery to the
cortex, or altering the central perception
of pain.
PHARMACOLOGICAL
APPROACHES
 The
selection of a particular
pharmacological analgesic agent
depends on:
1 . Cause of pain
2 . Length of time the individual is
expected to need the agent.
3 . The side effects of the agent
SYSTEMIC ANALGESICS
 Administration
of a systemic analgesic
is usually the primary method of pain
management.
 It is easy to administer and inexpensive,
and can be an effective and appropriate
pain-relieving intervention for many
patients.
SYSTEMIC ANALGESICS
 A wide
range of analgesic medications
can be systemically administered orally
or by other routes.
 These medications include nonsteroidal anti-inflammatory drugs
(NSAIDs), acetaminophen, opiates and
opiods, and antidepressants.
NONSTEROIDAL ANTIINFLAMMATORY DRUGS
 NSAIDs
have both analgesic and antiinflammatory properties and can
therefore relieve pain from both
inflammatory and non-inflammatory
sources.
 The primary long-term complication of
NSAID use is gastrointestinal irritation
and bleeding.
NONSTEROIDAL ANTIINFLAMMATORY DRUGS
 NSAIDs
also cause decreased platelet
aggregation and thus prolonged
bleeding time.
 They can cause kidney damage, bone
marrow suppression, rashes and
anorexia., and decrease renal blood
flow in dehydrated patients.
SOURCES OF
 The
first NSAID was aspirin.
 Ibuprofen (Motrin), naproxen sodium
(Naprosyn, Aleve), and Piroxicam
(Feldene), are now available over the
counter and by prescription.
 NSAIDs are primarily administered
orally, although one, ketoraolac
(Toradol), is available for administration
by injection.
ACETAMINOPHEN
 Acetaminophen
(Tylenol) is an effective
analgesic for mild to moderately severe
pain; however, unlike NSAIDs, it has no
clinically significant anti-inflammatory
activity. It is useful for those who cannot
tolerate NSAIDs due to gastric irritation
or when the prolongation of bleeding
time caused by NSAIDs would be a
disadvantage.
ACETAMINOPHEN
 Prolonged
use or large doses of
acetaminophen can cause liver
damage; this risk is elevated in the
chronic alcoholic. Skin rashes are also
an occasional side effect of this
medication.
OPIATES
 Opiates
are narcotic drugs that contain
opium, derivatives of opium, or any of
several semisynthetic or synthetic drugs
with opium-like activity.
 Morphine, hydro-morphone, fentanyl,
and meperidine are examples of opiates
commonly used for clinical applications.
OPIATES
 It
has been proposed that opiates
provide analgesia by mimicking the
effects of endorphins and binding to
opiate-specific receptor sites in the
CNS.
 Opiates, when given in sufficient doses,
will control even the most severe acute
pain with tolerable side-effects .
OPIATES
 They
control pain that cannot be
relieved by non-narcotic agents and are
most effective when the pain is dull and
poorly localized.
OPIATES
 The
side effects of opiates, including
nausea, vomiting, sedation, suppression
of cough, gastrointestinal mobility, and
respiration, as well as their propensity to
cause physical dependence and
depression with long-term use, limit
their application for the long term
management of musculoskeletal pain.
OPIATES
 Respiratory
depression also limits the
dose that can be used even for short
term administration.
 Opiates are generally used clinically to
relieve postoperative pain or pain due to
malignancy.
OPIATES
 Opiates
can be delivered my mouth,
intravenously, or by direct intra-articular
injection.
 A popular and effective means of
administration , particularly for
hospitalized patients, is patientcontrolled analgesia (PCA).
OPIATES
 With
PCA, patients self-administer
small, repeated intravenous doses via a
pump.
 The amount of medication delivered is
limited by pre-establishing dosing
intervals and maximum doses within a
defined period.
OPIATES
 Pain
control is more effective and
adverse effects are less common with
this means of administration than with
more conventional physician-controlled
opiate administration methods.
ANTIDEPRESSANTS
 Antidepressants,
particularly the
tricyclics such as amitryptiline (Elavil),
have been found to be an effective
adjunctive component of chronic pain
treatment, with smaller doses being
effective for this application than those
typically used for the treatment of
depression.
ANTIDEPRESSANTS
 The
efficacy of these drugs for the
treatment of chronic pain is thought to
be related to their effects on sleep,
nerve function, and mood.
 It has been found that patents with
chronic pain who are also depressed
report much higher levels of pain and
show more pain related behaviors than
those who are not depressed.
ANTIDEPRESSANTS
 Although
it is not certain if the higher
level of pain in such patients is the
cause or the product of their
depression, the use of antidepressants
in either situation may prove beneficial.
SPINAL ANALGESIA
 Pain
relief may be achieved by the
administration of drugs such as opiates,
local anesthetics, or corticosteroids into
the epidural or subarachnoid space of
the spinal cord.
SPINAL ANALGESIA
 The
route of administration provides
analgesia to the areas innervated by the
segments of the cord receiving the drug
and is therefore most effective when the
pain has a spinal distribution, such as a
dermatomal distribution in a single limb.
SPINAL ANALGESIA
 The
primary advantages of this route of
administration are that the drug
bypasses the blood-brain barrier and
that high concentrations reach the
spinal cord at sites of nociceptive
transmission and at opiate receptors,
thus increasing the analgesic effects
while reducing adverse effects.
SPINAL ANALGESIA
 Opiates
administered spinally exert their
effects by stimulating opiate receptors in
the dorsal horn of the spinal cord.
 When administered spinally, fat soluble
opiates have a rapid onset and a short
duration of action, whereas water
soluble opiates have a slow onset and a
more prolonged duration of action.
SPINAL ANALGESIA
 Local
anesthetics delivered spinally
have the unique ability to completely
block nociceptive transmission;
however, with increasing concentration,
these drugs also block sensory and
then motor transmission, causing
numbness and weakness.
SPINAL ANALGESIA
 High
doses of these drugs can also
cause hypotension.
 These side effects of local anesthetics
limit their application to the short-term
control of pain and diagnostic purposes.
SPINAL ANALGESIA
 Catabolic
corticosteroids, such as
cortisone and dexamethasone, can be
administered to the epidural or
subarachnoid space in order to relieve
pain due to inflammation of the spinal
nerve roots and/or surrounding
structures.
SPINAL ANALGESIA
 These
drugs inhibit the inflammatory
response to tissue injury; however , due
to the side effects of repeated or
prolonged use, including fat and muscle
wasting, osteoporosis, and symptoms of
Cushing’s syndrome, these drugs are
not suitable for long-term application.
LOCAL INJECTION
 Local
injection of a corticosteroid and/or
a local anesthetic can be particularly
effective for relieving pain associated
with local inflammation.
 Such injections can be administered
into joints, bursae, trigger points, or
around tendons and can be used for
therapeutic purposes, to relieve pain,
and/or for diagnostic purposes, to help
identify the structures at fault.
LOCAL INJECTION
 Although
this type of treatment can be
very effective, repeated local injections
of corticosteroids are not recommended
because they can cause tissue
breakdown and deterioration.
 Local injections of corticosteroids
directly after acute trauma are also not
recommended because these drugs
reduce the inflammatory response and
may thus impair healing.
LOCAL INJECTION
 Local
injections of anesthetics generally
provide only short-term relief and are
therefore used primarily during painful
procedures or diagnostically.
PHYSICAL AGENTS
 Many
physical agents effectively control
or relieve pain.
 They exert this effect by moderating the
release of inflammatory mediators,
modulating pain at the spinal cord level,
altering nerve conduction, and.or
increasing endorphin levels.
PHYSICAL AGENTS
 They
also may indirectly reduce pain by
decreasing the sensitivity of the muscle
spindle system,thereby reducing muscle
spasms, or by modifying vascular tone
and the rate of blood flow, thereby
reducing edema or ischemia.
 In addition, physical agents may reduce
pain by helping to resolve the
underlying cause of the painful
sensation.
PHYSICAL AGENTS
 Different
physical agents control pain in
different ways,
 Cryotherapy - controls acute pain in part
by reducing the metabolic rate and thus
reducing the production and release of
inflammatory mediators such as
serotonin, histamine, bradykinin,
substance P, and prostaglandins.
PHYSICAL AGENTS
 These
chemicals cause pain directly by
stimulating nociceptors and indirectly by
impairing the local microstimulation and,
in so doing, can damage tissue and
impair tissue repair.
 Reducing the release of inflammatory
mediators can thus directly relieve pain
caused by acute inflammation and may
directly limit pain by controlling edema
and ischemia.
PHYSICAL AGENTS
 These
short term benefits can also
optimize the rate of tissue healing and
recovery.
 Cryotherapy, thermotherapy, electrical
stimulation, and traction, which provide
thermal, mechanical, or other nonnociceptive sensory stimuli, are thought
to alleviate pain in part by inhibiting pain
transmission at the spinal cord.
PHYSICAL AGENTS
 Physical
agents that act by this
mechanism can be used for the
treatment of acute and chronic pain
because they do not generally produce
significant adverse effects or adverse
interactions with drugs, and they do not
produce physical dependence with
prolonged use.
PHYSICAL AGENTS
 They
are also effective and appropriate
for pain caused by conditions that
cannot be directly modified, such as
pain caused by malignancy or a recent
fracture, and for pain due to peripheral
nervous system pathology, such as
phantom limb pain, and peripheral
neuropathy.
PHYSICAL AGENTS
 Electrical
stimulation is also thought to
control pain in part by stimulating the
release of endorphins at the spinal cord
and at higher levels.
 This belief is supported by the finding
that pain relief by certain types of
electrical stimulation is reversed by
naloxone.
PHYSICAL AGENTS
 Physical
agents have a number of
advantages over other pain-modifying
interventions.
 They are associated with fewer, and
generally less severe, side effects than
pharmacological agents.
 The adverse effects from using physical
agents to control pain are generally
localized to the area of application and
are easily avoided with care in applying
treatment.
PHYSICAL AGENTS
 Patients
also do not develop
dependence on physical agents,
although they may wish to continue to
use them even after they are no longer
effective because they enjoy the
sensation or attention associated with
their application.
PHYSICAL AGENTS
 Physical
agents also do not generally
cause a degree of sedation that would
impair an individual’s ability to work or
drive safely.
 Many physical agents have the
additional advantage of being readily
used by patients independently to treat
themselves.
PHYSICAL AGENTS
 This
type of treatment can also assist in
containing the costs of medical care.
 Physical agents, used either alone or in
conjunction with other interventions,
such as pharmacological agents,
manipulation, exercises, can also help
remediate the underlying cause of pain
while controlling the pain itself.
MULTIDISCIPLINARY PAIN
TREATMENT PROGRAMS
 Over
the past two to three decades,
multidisciplinary programs have been
developed specifically for the treatment
of chronic pain.
 Goals of treatment also generally
include decreasing dependence on
health care personnel and pain relieving medications, particularly habit
forming opiates or other narcotics,
increasing physical activities,
MULTIDISCIPLINARY PAIN
TREATMENT PROGRAMS
 Referral
to alternative health care
providers, and returning patients to their
usual social roles.
 A number of studies have shown that
multidisciplinary pain treatment
programs do result in increased
functional activity levels while reducing
pain behaviors and the use of medical
interventions in patients with chronic
pain
MULTIDISCIPLINARY PAIN
TREATMENT PROGRAMS
 These
programs have also been
shown to be cost effective.
MICROCURRENT
DR. GRANT
255
Pain Alliance Institute
MICROCURRENT
This type of electrical modality
uses an electrical current of less
than 1 mA.
They are subthreshold in nature
and patients usually do not
experience either the tingling
sensation or muscle contraction
seen with other electrical
stimulators.
MICRO CURRENT THERAPY
EFFECTS
Changes
in cell wall permeability
Increased intracellular
concentration of Ca.
Increased ATP production
Increased protein synthesis
Increased fibroblast activity
257
MICRO CURRENT THERAPY
The
most widely accepted view
concerns the effect these small
currents have on the cell
membrane.
It is generally accepted that
microamperage current produces
two important effects:
1 .“opens” voltage sensitive ion
channels in the cell membrane
258
MICRO CURRENT THERAPY
2 .Increases the intracellular
concentration of Ca and Na ions
Damaged
tissue releases a variety
of pain producing substances
including arachidonic acid.
Arachidonic acid, in turn, is used in
the synthesis of prostaglandin's
and is associated with the
production of histamine and
bradykinins.
259
MICRO CURRENT THERAPY
3 .Chemical agents (pharmaceuticals)
that interfere with the process.
The
most permanent approach to
relieving pain would be to stimulate
the intracellular mechanisms that
would repair the damaged
membranes that are responsible for
the leakage of the pain-blocking
agents.
261
MICRO CURRENT THERAPY
It
is postulated that microamperage
stimulation functions to repair the
injured cell membrane which, in
turn, leads to a reduction of pain.
Perhaps the most troubling area in
the use of microamperage
stimulation devices is the lack of
understanding and uniformity of
stimulation parameters.
262
MICRO CURRENT THERAPY
To
date, selection of appropriate
parameters (frequency, intensity,
pulse width, duration of treatment,
etc.) are largely based on empirical
observations and clinical
experience.
It does appear that the following
parameters represent reasonable
suggestions based on the available
data.
263
MICRO CURRENT THERAPY
Direct
current is preferred due to
the fact that it has a polarizing
effect.
Polarity - this may be the most
crucial factor. It is generally
accepted that a positive current is
most useful in the early phases of
treatment and a negative current in
later phases.
264
MICRO CURRENT THERAPY
Pulse
width - in order to make the
stimulus sufficient to change the
cell membrane potential, it appears
that a relatively long pulse width is
necessary. Pulse widths vary from
50 microseconds to as long as .5
seconds.
265
MICRO CURRENT THERAPY
Frequency
- Acupuncture point
stimulation appears to be most
effective at low pulse rates,
between 1-5 Hz.
Pulse rates with microcurrent
stimulation devices range from .5
per second to several hundred per
second.
266
MICRO CURRENT THERAPY
It
is suggested that lower pulse
rates are used for chronic
conditions and higher pulse rates
for more acute problems.
267
MICRO CURRENT THERAPY
POINT STIMULATION
Although
microcurrent probe
technique requires the active
participation of the doctor or
therapist, many believe that pain
relief and an increase in joint range
of motion can be accomplished in
far less time than needed for other
electrotherapy modalities.
268
MICRO CURRENT THERAPY
PROBES
Typically,
the initial stage of
treatment uses a hand-held probe
that is either a solid blunt probe or
a probe with a moistened cotton
swab inserted within the hollowed
tip of the probe.
269
MICRO CURRENT THERAPY
PROBES
When
using probes, first affix new
felt electrodes and saturate them
with saline solution.
Then apply firm pressure, but less
than that which would cause more
pain.
271
MICRO CURRENT THERAPY
PROBES
Tap
water does not work well in
most places anymore because of
recent advances in desalination
during water processing.
As saline is a prescription product
in the U.S., you can use contact
lens cleaner, a conveniently
packaged and inexpensive overthe-counter form of saline.
MICROCURRENT
APPLICATION
For
extremely hypersensitive
people, such as fibromyalgia
patients, it is better to start with a
minimal amount of current.
Even low level Micro currents may
be uncomfortable in some patients.
Start with more sensitive electrodes
in these patients ( carbon, silver
electrodes, probes with tap water)
MICROCURRENT
APPLICATION
The
patient should be in a relaxed
position to receive maximum
beneficial effects.
The most important variable is the
position of the probes, or pads.
Place the probes or electrodes in
such a way that if a line was drawn
between them, that line would
transect the problem area.
MICROCURRENT
APPLICATION
Keep
in mind that the electrode
positioning may be transient,
working well one day, but
ineffective another day.
As the problem begins to resolve,
the electrode locations may require
constant adjustments
MICRO CURRENT THERAPY
Many
doctors are familiar with
acupoints, motor points, and trigger
points and are experienced in their
electrostimulation.
Once these points are isolated, the
current is set to a subsensory level
and the points are stimulated (15
seconds).
276
MICRO CURRENT THERAPY
NERVE ROOT TECHNIQUE
In
this method, both probes are
used to stimulate adjacent
interspinous spaces of involved
vertebral segments for 12 - 20
seconds.
Significantly enhanced pain control
and improved segmental ROM
have been reported when using this
technique.
277
MICRO CURRENT THERAPY
Enhancing
restricted joint motion
has been reported to be highly
effective when combined with
passive mobilization of the involved
joint.
Results are typically greater than
when passive exercise is used
alone to increase joint ROMs.
278
MICRO CURRENT THERAPY
PAD TREATMENT
When
pads are used, placement is
proximal and distal to the site of
involvement.
279
MICRO CURRENT THERAPY
INDICATIONS
Pain
Tissue
healing, including decubitus
ulcers
Several microamperage stimulators
are being used for the treatment of
acute and chronic sports injuries
because of their analgesic, antiinflammatory, and healing
properties
280
MICRO CURRENT THERAPY
CONTRAINDICATIONS
Demand
- type cardiac pacemakers
Over the carotid sinus
Over the eyeball or eyelid
Safety and effectiveness of
microamperage stimulators has not
been established in pregnancy;
avoid the stimulation of any area
that might affect the pregnancy.
281
MICOCURRENT
 These
units are not designed to
stimulate a muscle contraction
 As a result, these units are now referred
to as LIS (Low intensity stimulators).
 These currents still have a direction,
and both AC and DC waveforms are
available.
MICROCURRENT
Questions regarding
Microcurrent therapy?
COMBINATION THERAPY
 In
a clinical setting it is not uncommon
to combine modalities to accomplish a
specific treatment goal.
 Ultra sound is frequently used with other
modalities including cold packs, and
electrical stimulating currents.
 Pulsed ultrasound could be used after
ice application if the goal is pain
reduction and healing in the acute
stage.
ULTRASOUND AND ESC
 The
combination of these two are
frequently used.
 Electrical stimulating currents are used
for analgesia or producing muscle
contraction.
 Ultrasound and ESC in combination
have been recommended in the
treatment of myofascial trigger points.
ULTRASOUND AND ESC
 Both
modalities provide analgesic
effects, and both have been shown to
be effective in reducing the pain-spasmpain cycle, although the mechanisms
responsible are not clearly understood.
ESC & ULTRASOUND
CONNECTION IN BACK OF
ULTRASOUND
BACK OF UNIT
CONNECTION
BANANA PLUG
QUESTIONS REGARDING
COMBINATION THERAPY?