Your SlideShare is downloading. ×
Clinical Application of
Electrical Stimulation
Casey Christy, MA, ATC, CSCS
Knobology
“Knobology is a ‘tongue-in-cheek’ term for the study
of application without theory…the term for students
and cli...
Knobology
A knobologist simply turns the estim unit on and selects any
waveform or frequency presets without regard to spe...
Physician Direction
Note that state practice acts vary regarding the
administration of electrical stimulation and other
th...
Reasons We Use Electrical
Stimulation
Pain Reduction
Muscle Re-Education
Edema Prevention/Curbing
Edema Reduction
Reductio...
Basic Current Types
Alternating Current
Direct Current
Pulsatile (pulsed) Current
Monophasic: Has only positive OR negativ...
Alternating Current (AC)
Continuous waveform consisting of positive
and negative phases. The polarity and each end
of the ...
Direct Current (DC)
A continuous current without positive and
negative phases.
Clinical Application: DC is used for
iontop...
Interferential Current
The crossing of two slightly different medium frequency
currents via the use of a quadripolar techn...
Interferential Current
Image courtesy of therapeuticmodalities.com, Starkey,
Therapeutic Modalities 3rd
Edition, FA Davis ...
Premodulated Current
A bipolar technique in which the two frequencies
are “mixed” inside the machine prior to tissue
deliv...
High Volt Current
A monophasic, twin-peaked waveform, with a
short phase duration and a long interpulse
interval.
Clinical...
Russian Current
Sinusoidal, polyphasic AC-type current that
occurs in 10 millisecond “bursts” interrupted
by a 10 millisec...
Treating for Pain
Gate-Theory sensory electrical stimulation:
Short phase duration (<100 microseconds)
High frequency (ie:...
Treating for Pain
Motor-level electrical stimulation:
Longer phase duration (300-400 microseconds)
Low frequency (2-4pps)
...
Treating for Muscle Re-Education
Motor-level electrical stimulation:
Longer phase duration (200-400 microseconds)
Russian ...
Treating for Muscle Re-Education
Visible, comfortable muscle contraction
– Patient encouraged to contract with estim-induc...
Treating for Edema
Prevention
• Sensory electrical stimulation
– Also called “edema curbing”
– Monopolar setup, immersion ...
Treating for Edema
Prevention
– 20-30 minute treatment
time
– Apply within 6 hours of
acute injury
– Gravity-dependant
pos...
Treating for Edema Reduction
• Motor-level electrical stimulation
– Also called “muscle-milking”
– Bipolar setup on muscle...
Treating for Edema Reduction
Image courtesy of therapeuticmodalities.com, Starkey,
Therapeutic Modalities 3rd
Edition, FA ...
Terms to Know for Setup
• Amplitude: Intensity
• Frequency: The number of times an event occurs in
one second, or the numb...
Terms to Know for Setup
• Beat Frequency: Occurs when two waveforms are in and out
of phase. Difference between the two fr...
Terms to Know for Setup
• Scan: Varies the intensity to reduce
accommodation. Also known as amplitude
modulation.
• Sweep:...
Terms to Know for Setup
• Vector Scan: “Rotates the cloverleaf” when using
interferential. Also known as rotating vector s...
About “TENS” Units
• “TENS” means Transcutaneous Electrical Neuromuscular
Stimulation
• By definition all estim can be con...
Combo Treatment
• Combining ultrasound and electrical
stimulation
• Touted as a good method to reduce muscle
spasm
• Be aw...
Wound Healing
• High Volt used in studies on ulcerations
• Polarity setting may be trial and error
– Start with negative
–...
General Contraindications
• Pacemaker
• Cardiac or other circulatory conditions
• Epilepsy
• Pregnancy
• Medication allerg...
Common Practical Exam
Mistakes
• Not knowing how to turn off/on sweep or scan, or not
knowing that it is off when it shoul...
Common Practical Exam
Mistakes
• Not knowing various estim protocols covered in lab
• Not knowing which channel/electrode ...
References
• Denegar et al, Therapeutic Modalities for
Musculokeletal Injuries, 3rd
edition.
• Knight and Draper, Therapeu...
Upcoming SlideShare
Loading in...5
×

Electrical Stimulation Clinical Application Review

29,517

Published on

1 Comment
18 Likes
Statistics
Notes
No Downloads
Views
Total Views
29,517
On Slideshare
0
From Embeds
0
Number of Embeds
4
Actions
Shares
0
Downloads
0
Comments
1
Likes
18
Embeds 0
No embeds

No notes for slide

Transcript of "Electrical Stimulation Clinical Application Review"

  1. 1. Clinical Application of Electrical Stimulation Casey Christy, MA, ATC, CSCS
  2. 2. Knobology “Knobology is a ‘tongue-in-cheek’ term for the study of application without theory…the term for students and clinicians who want to know only which knobs on a therapeutic modality to turn and are uninterested in why they are doing so. Not only would there be little advancement in medicine if all clinicians were knobologists, but patients would suffer from inadequate treatment. Don’t be a knobologist!” (from Knight and Draper, Therapeutic Modalities: The Art And Science)
  3. 3. Knobology A knobologist simply turns the estim unit on and selects any waveform or frequency presets without regard to specific treatment goals. A well-prepared clinician is capable of selecting the appropriate waveform, frequency and intensity for the desired treatment effect. A knobologist does not utilize additional treatment options to maximize patient benefit when appropriate. A well-prepared clinician applies parameters such as amplitude modulation, frequency modulation or vector scan as indicated, and is capable of modifying items such as phase duration and duty cycle when appropriate.
  4. 4. Physician Direction Note that state practice acts vary regarding the administration of electrical stimulation and other therapeutic modalities by certified athletic trainers. NJ requires that certified athletic trainers may only administer electrical stimulation at the direction of a physician. This includes standing orders or a physician script. Standing orders should be reviewed, updated and signed annually by the athletic trainer and supervising physician.
  5. 5. Reasons We Use Electrical Stimulation Pain Reduction Muscle Re-Education Edema Prevention/Curbing Edema Reduction Reduction in Muscle Spasm Denervated Muscle Inflammation (Iontophoresis) Wound Healing
  6. 6. Basic Current Types Alternating Current Direct Current Pulsatile (pulsed) Current Monophasic: Has only positive OR negative phases. High Volt Stim is an example of monophasic current. Biphasic Current: Has both positive and negative phases. The current can be symmetrical, asymmetrical, balanced or unbalanced. Polyphasic Current: Has multiple phases between interpulse intervals. Interferential, Pre-Mod and Russian are examples of polyphasic current.
  7. 7. Alternating Current (AC) Continuous waveform consisting of positive and negative phases. The polarity and each end of the circuit is constantly being reversed. Clinical Application: AC can be used for pain relief as well as for neuromuscular stimulation.
  8. 8. Direct Current (DC) A continuous current without positive and negative phases. Clinical Application: DC is used for iontophoresis and to stimulate denervated muscle. There is an increased risk of skin burns with DC current. Physician prescription required for medication.
  9. 9. Interferential Current The crossing of two slightly different medium frequency currents via the use of a quadripolar technique, resulting in deeper tissue penetration. Some units have a rotating vector system that periodically changes the orientation of the electrical field 45°to reduce accommodation (efficacy not substantiated) or to make certain estim reaches target area. Clinical Application: Interferential is primarily used for pain control over an area large enough to accommodate 4 electrodes such as the shoulder, back and thigh.
  10. 10. Interferential Current Image courtesy of therapeuticmodalities.com, Starkey, Therapeutic Modalities 3rd Edition, FA Davis Publishers
  11. 11. Premodulated Current A bipolar technique in which the two frequencies are “mixed” inside the machine prior to tissue delivery. Clinical Application: Premodulated current may be used for pain control, or edema reduction via the “muscle-milking” technique. Smaller areas that are unable to accommodate a quadripolar interferential application are appropriate for pre-mod current.
  12. 12. High Volt Current A monophasic, twin-peaked waveform, with a short phase duration and a long interpulse interval. Clinical Application: High Volt is typically used for pain control and edema prevention/curbing.
  13. 13. Russian Current Sinusoidal, polyphasic AC-type current that occurs in 10 millisecond “bursts” interrupted by a 10 millisecond “off” time. These interruptions occur so fast they are imperceptible by the patient. 50 bursts occur per second and there are 25 cycles (50 pulses) per burst. Clinical Application: Russian is typically used for muscle re-education.
  14. 14. Treating for Pain Gate-Theory sensory electrical stimulation: Short phase duration (<100 microseconds) High frequency (ie: 60-120pps) Sensory estim only, no muscle contraction Acute pain: combine with ice Post-acute pain: combine with moist heat if not contraindicated 15-20 minute treatment time
  15. 15. Treating for Pain Motor-level electrical stimulation: Longer phase duration (300-400 microseconds) Low frequency (2-4pps) Starkey: muscle contraction Denegar: Noxious, “needling” estim without contraction Chronic pain 20 minute treatment time Do not use muscle contraction if contraindicated or could worsen sx
  16. 16. Treating for Muscle Re-Education Motor-level electrical stimulation: Longer phase duration (200-400 microseconds) Russian preferred but may use AC or biphasic if can set on:off times and obtain comfortable, quality contraction Frequency 30-70pps (50-60 pps considered ideal) 1:3, 1:5 on:off time ratio; 10 second on time recommended
  17. 17. Treating for Muscle Re-Education Visible, comfortable muscle contraction – Patient encouraged to contract with estim-induced contraction – Post-op ACL common • Some surgeons advise 10 lb counterweight on tibia – 15-20 minute treatment time
  18. 18. Treating for Edema Prevention • Sensory electrical stimulation – Also called “edema curbing” – Monopolar setup, immersion method – Negative electrode at injured area; large positive dispersal pad on thigh – High volt, 120pps, negative polarity, 10% below motor threshold shown in animal models to curb edema formation
  19. 19. Treating for Edema Prevention – 20-30 minute treatment time – Apply within 6 hours of acute injury – Gravity-dependant position and lack of compression main negative aspects; provide in-between treatments Image courtesy of therapeuticmodalities.com, Starkey, Therapeutic Modalities 3rd Edition, FA Davis Publishers
  20. 20. Treating for Edema Reduction • Motor-level electrical stimulation – Also called “muscle-milking” – Bipolar setup on muscle proximal to edema – Low frequency (2-4 pps) – Visible, comfortable muscle contraction – Elevate – Apply 15 minutes with cold application – Make certain muscle contraction is not contraindicated – Can also apply alternating current between the 2 muscle groups proximal to edema (ie: gastroc and hamstrings for ankle edema) • If using alternating contractions, use 100pps
  21. 21. Treating for Edema Reduction Image courtesy of therapeuticmodalities.com, Starkey, Therapeutic Modalities 3rd Edition, FA Davis Publishers
  22. 22. Terms to Know for Setup • Amplitude: Intensity • Frequency: The number of times an event occurs in one second, or the number of electrical impulses (or cycles) delivered to the tissues. – Measured in hertz (cycles per second) to describe continuous current, or the “carrier” or “base” frequency of the electrical stimulator. – Measured in pps (pulses per second) to describe the number of electrical pulses (or cycles) delivered tissues using a pulsed current
  23. 23. Terms to Know for Setup • Beat Frequency: Occurs when two waveforms are in and out of phase. Difference between the two frequencies is called “beat frequency” (ie: carrier frequencies of 4000 and 4150 will yield a 150 pps beat frequency). Used with Interferential. • Phase Duration: The time it takes to complete one phase of a pulse. This is important because the length affects the type of nerve fiber recruited. • Phase Charge: The measure of electrons delivered in each phase of a pulsatile current. Although few machines display it, phase charge can be altered by adjusting the phase duration and amplitude.
  24. 24. Terms to Know for Setup • Scan: Varies the intensity to reduce accommodation. Also known as amplitude modulation. • Sweep: Varies the frequency to reduce accommodation. Also known as frequency modulation. • Duty cycle: The ratio of “on” and “off” time. This setting is used to deliver interrupted current.
  25. 25. Terms to Know for Setup • Vector Scan: “Rotates the cloverleaf” when using interferential. Also known as rotating vector system. • Ramp time: Used when setting a gradual increase in intensity during the “on-time” when applying muscle re-education.
  26. 26. About “TENS” Units • “TENS” means Transcutaneous Electrical Neuromuscular Stimulation • By definition all estim can be considered “TENS” • Small battery-powered units are commonly referred to as “TENS units” • These units typically deliver and asymmetric biphasic waveform • Units may provide ability to alter frequency and pulse width (phase duration) • Commonly used for pain control
  27. 27. Combo Treatment • Combining ultrasound and electrical stimulation • Touted as a good method to reduce muscle spasm • Be aware of specific channel/electrode that must be used for combo to work
  28. 28. Wound Healing • High Volt used in studies on ulcerations • Polarity setting may be trial and error – Start with negative – Change to positive it healing hits plateau – May need to switch after several days or when healing hits plateau • 100 pps frequency, low intensity • Active electrode over or along edge of wound
  29. 29. General Contraindications • Pacemaker • Cardiac or other circulatory conditions • Epilepsy • Pregnancy • Medication allergy/hypersensitivity for ionto • Electrode location – Never over the head, carotid artery or areas of decreased sensation – If in doubt check with physician
  30. 30. Common Practical Exam Mistakes • Not knowing how to turn off/on sweep or scan, or not knowing that it is off when it should be on or vice versa • The model does not feel anything because you are using/adjusting/plugged into the wrong channel • Improper Interferential electrode setup. Here is correct channel locations: pain Ch 1 Ch 1 Ch 2 Ch 2
  31. 31. Common Practical Exam Mistakes • Not knowing various estim protocols covered in lab • Not knowing which channel/electrode to use for combo treatment, or how to independently adjust/set ultrasound and estim • Failure to practice or going through the motions in lab often results in unfamiliarity with the machine that becomes evident during exam
  32. 32. References • Denegar et al, Therapeutic Modalities for Musculokeletal Injuries, 3rd edition. • Knight and Draper, Therapeutic Modalities: The Art And Science), 2nd edition. • Starkey, Therapeutic Modalities, 4th edition.

×