Electrical Stimulation Goals And Treatment

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Electrical Stimulation Goals And Treatment

  1. 1. Electrical Stimulation Goals and Treatment Adapted from Therapeutic Modalities: Art & Science , Knight & Draper (2008) for KIN 195
  2. 2. Competencies for Therapeutic Modalities TM-C2 Explain the principles of physics, including basic concepts associated with the electromagnetic and acoustic spectra (e.g., frequency, wavelength) associated with therapeutic modalities. TM-C3 Explain the terminology, principles, basic concepts, and properties of electric currents as they relate to therapeutic modalities. TM-C4 Describe contemporary pain-control theories.
  3. 3. Competencies for Therapeutic Modalities, cont. TM-C6 Explain the body's physiological responses during and following the application of therapeutic modalities. TM-C7 Describe the electrophysics, physical properties, biophysics, patient preparation and modality set-up (parameters), indications, contraindications, and specific physiological effects associated with commonly used therapeutic modalities. TM-C8 Identify appropriate therapeutic modalities for the treatment and rehabilitation of injuries and illness.
  4. 4. Basics of Electricity <ul><li>Must understand why as well as how to use electrical stimulation. </li></ul><ul><li>Or </li></ul><ul><li>You’ll be a knobologist. </li></ul>
  5. 5. Review: Requirements for Ion Migration: Chemical Effects <ul><li>Must have continuous monophasic DC electron flow to cause ion migration. </li></ul><ul><li>Moving electrons against gradient </li></ul><ul><ul><li>Like pushing a car uphill </li></ul></ul><ul><ul><li>When you pause, it rolls back down. </li></ul></ul><ul><li>Why does a twin-pulse high-volt current not produce a chemical effect? </li></ul>
  6. 6. Review: Polarization & Action Potentials <ul><li>Stimulation requires a polarized membrane (between inside and outside of nerve membrane). </li></ul><ul><ul><li>More positive ions than negative ions outside nerve and more negative ions than positive ions inside membrane </li></ul></ul><ul><ul><li>When polarized, membranes have a potential of − 70 to − 90 mV between inside and outside of membrane </li></ul></ul>
  7. 7. Review: Polarization and Action Potentials (cont.) <ul><li>Nerve action potential eventually causes </li></ul><ul><ul><li>An ascending sensory impulse to the brain </li></ul></ul><ul><ul><li>Or </li></ul></ul><ul><ul><li>A descending muscle action potential </li></ul></ul><ul><li>Muscle action potential causes muscle contraction. </li></ul>
  8. 8. Review: Polarization and Action Potentials (cont.) <ul><li>Nerve repolarizes quickly. </li></ul><ul><li>Absolute refractory periods vary from 0.4 to 2 msec </li></ul><ul><ul><li>Depends on specific nerve </li></ul></ul>
  9. 9. Review Excitability: Nerve Size and Depth <ul><li>The larger the nerve, the easier it can be stimulated. </li></ul><ul><li>The more superficial the nerve, the easier it can be stimulated. </li></ul><ul><li>In a practical sense: </li></ul><ul><ul><li>Large sensory nerves are more excitable than motor nerves. </li></ul></ul><ul><ul><li>Motor nerves are more excitable than pain fibers. </li></ul></ul>
  10. 10. Review Excitability: Rate or Frequency <ul><li>Doesn’t effect individual threshold </li></ul><ul><ul><li>Effects torque as it approaches tetany </li></ul></ul><ul><ul><li>Increased rate means increased fatigue rate. </li></ul></ul>fatigue tetany 5/sec
  11. 11. Review Electrodes: Physical Dimensions <ul><li>Shape is unimportant </li></ul><ul><ul><li>Most are round or square or rectangular. </li></ul></ul><ul><li>Size and placement determine the number of motor units stimulated. </li></ul>
  12. 12. Review Electrode Function <ul><li>Active electrode </li></ul><ul><ul><li>Electrode under which the current density is great enough to elicit the desired response </li></ul></ul><ul><li>Indifferent (dispersive) electrode </li></ul><ul><ul><li>Electrode under which the current density is not great enough to elicit the desired response </li></ul></ul>
  13. 13. Most Commonly Used Wave Forms <ul><ul><li>DC: DC </li></ul></ul><ul><ul><li>IF: Polyphasic </li></ul></ul><ul><ul><li>HV: Twin pulse </li></ul></ul><ul><ul><li>LV : Biphasic and polyphasic burst (Russian) </li></ul></ul><ul><ul><li>TENS: Biphasic </li></ul></ul>
  14. 14. Review: Pulse and Cycle Characteristics <ul><li>Pulse: finite period of charged particle movement, separated from other pulses by a finite time during which no current flows </li></ul><ul><li>Made up of one or more phases </li></ul>
  15. 15. Review: Pulse and Cycle Characteristics (cont.) <ul><li>Pulse named by number of phases </li></ul><ul><ul><li>Monophasic </li></ul></ul><ul><ul><ul><li>One phase </li></ul></ul></ul><ul><ul><ul><li>Current flows in one direction only. </li></ul></ul></ul><ul><ul><li>Biphasic </li></ul></ul><ul><ul><ul><li>Two phases </li></ul></ul></ul><ul><ul><ul><li>Current flows in both directions. </li></ul></ul></ul><ul><ul><li>Polyphasic </li></ul></ul><ul><ul><ul><li>Many phases </li></ul></ul></ul>
  16. 16. Review: Burst Characteristics <ul><li>Burst </li></ul><ul><ul><li>Finite series of pulses flowing for a finite time period followed by no current flow </li></ul></ul><ul><ul><ul><li>Think of it as turning a pulse train or AC current on and off. </li></ul></ul></ul><ul><ul><li>Burst interval </li></ul></ul><ul><ul><ul><li>Time during which burst occurs </li></ul></ul></ul><ul><ul><li>Interburst interval </li></ul></ul><ul><ul><ul><li>Time between bursts, usually in milliseconds </li></ul></ul></ul>
  17. 17. Review: Current Timing & Modulation <ul><li>Pulse width (pulse duration) </li></ul><ul><ul><li>Time required for each pulse to complete its cycle </li></ul></ul><ul><ul><li>Reported in microseconds or milliseconds </li></ul></ul><ul><li>Short pulse duration: <150 µ sec </li></ul><ul><li>Long pulse duration: >200 µ sec </li></ul><ul><li>Interpulse interval </li></ul><ul><ul><li>Time between successive pulses </li></ul></ul>
  18. 18. Review: Surge Characteristics <ul><li>Ramp up </li></ul><ul><ul><li>Time during which the intensity increases </li></ul></ul><ul><li>Plateau </li></ul><ul><ul><li>Time during which pulses remain at maximum preset intensity </li></ul></ul><ul><li>Ramp down </li></ul><ul><ul><li>Time during which the intensity decreases </li></ul></ul>
  19. 19. Commonly Used Wave Forms (p.142) <ul><li>Direct (galvanic) wave form </li></ul><ul><ul><li>Pure DC current, used for iontophoresis </li></ul></ul>
  20. 20. Commonly Used Wave Forms (p. 142, cont.) <ul><ul><li>Monophasic, rectangular, pulsed </li></ul></ul><ul><ul><ul><li>Also called a modified square wave </li></ul></ul></ul><ul><ul><ul><li>Similar to DC but modulated from AC input current </li></ul></ul></ul><ul><ul><ul><li>On and off times are not necessarily equal </li></ul></ul></ul>
  21. 21. Commonly Used Wave Forms (p. 142, cont.) <ul><ul><li>Polyphasic, symmetrical, balanced, sinusoidal </li></ul></ul><ul><ul><ul><li>Wave form generated and sold by utility companies </li></ul></ul></ul>
  22. 22. Commonly Used Wave Forms (p. 142, cont.) <ul><li>Faradic wave form </li></ul><ul><ul><li>Induced asymmetrical AC current </li></ul></ul><ul><ul><li>Biphasic, asymmetric, unbalanced, spiked </li></ul></ul><ul><ul><li>Positive portion: short duration, high amplitude, and spiked </li></ul></ul><ul><ul><li>Negative portion: long duration, low amplitude, and curved </li></ul></ul>
  23. 23. Commonly Used Wave Forms (p. 142, cont.) <ul><li>Biphasic wave form </li></ul><ul><ul><li>Symmetrical, balanced, rectangular, pulsed </li></ul></ul>
  24. 24. Commonly Used Wave Forms (p. 142, cont.) <ul><li>Russian wave form </li></ul><ul><ul><li>Polyphasic, symmetrical, sinusoidal, burst </li></ul></ul><ul><ul><li>Developed by Russian scientist Kots; thus the name </li></ul></ul><ul><ul><li>Initially a 2500 Hz AC current burst, modulated every 10 msec, now many frequency choices </li></ul></ul>
  25. 25. Commonly Used Wave Forms (p. 142, cont.) <ul><li>Twin pulse wave form </li></ul><ul><ul><li>Monophasic, pulsed, twin spiked </li></ul></ul><ul><ul><li>Common wave form of high-volt muscle simulators </li></ul></ul><ul><ul><li>Has been called high-volt galvanic and pulsed direct current </li></ul></ul><ul><ul><li>However, not direct or galvanic current </li></ul></ul><ul><ul><li>Result of misunderstanding physiology </li></ul></ul>
  26. 26. Commonly Used Wave Forms (p. 142, cont.) <ul><li>Interferential wave form </li></ul><ul><ul><li>Symmetrical, sinusoidal, high frequency (2000 – 5000 Hz) AC </li></ul></ul><ul><ul><li>Two channels, with different frequencies, used simultaneously </li></ul></ul><ul><ul><li>Two currents cause a tissue current amplitude modulation </li></ul></ul>
  27. 27. Commonly Used Wave Forms (p. 142, cont.) <ul><li>Interferential wave form: current amplitude modulation </li></ul>Two identical currents Two opposite currents Two offset currents Usually accomplished with two different frequency currents
  28. 28. Use of Electrical Current Stimulation for Pain Relief <ul><li>Transcutaneous electrical nerve stimulation (TENS) </li></ul><ul><li>Interferential current therapy (IFC) </li></ul><ul><li>Iontophoresis </li></ul><ul><li>Neuromuscular electrical stimulation (NMES) </li></ul>
  29. 29. For all modalities… <ul><li>Know the effects, indications, contraindications, & precautions </li></ul><ul><li>Verify the modality is set up correctly before treatment begins </li></ul><ul><li>Prepare the patient psychologically & physically for the treatment </li></ul><ul><li>Begin treatment conservatively and ask for patient feedback </li></ul><ul><li>At the end of treatment, clean up the modality and instruct the patient about next treatment and activity level until then </li></ul><ul><li>Maintain the machines appropriately </li></ul>
  30. 30. TENS <ul><li>TENS </li></ul><ul><ul><li>Transcutaneous: through the skin </li></ul></ul><ul><ul><li>Electrical </li></ul></ul><ul><ul><li>Nerve: sensory </li></ul></ul><ul><ul><li>Stimulation: depolarize </li></ul></ul><ul><li>Stimulate sensory nerves with pulsed current via surface electrodes </li></ul>
  31. 31. TENS: Physiological Aspects <ul><li>Electrode placement </li></ul><ul><ul><li>Usually at the site of pain </li></ul></ul><ul><li>Clinician can change the patient’s perception of acute and chronic pain. </li></ul><ul><li>Selective depolarization of afferent nerves </li></ul>
  32. 32. How does TENS work? <ul><li>Many theories </li></ul><ul><li>Gate system and sensory TENS </li></ul><ul><ul><li>80 - 150 pps </li></ul></ul><ul><li>Endogenous Opiate system stimulated </li></ul><ul><ul><li>Motor TENS and brief-intense TENS </li></ul></ul><ul><ul><ul><li>Low beat frequency 1 – 5 pps </li></ul></ul></ul><ul><ul><ul><li>Slight muscle twitch </li></ul></ul></ul>
  33. 33. Brief Research Findings on TENS <ul><li>Research is difficult. </li></ul><ul><li>TENS has relieved pain associated with </li></ul><ul><ul><li>Osteoarthritis </li></ul></ul><ul><ul><li>Rheumatoid arthritis </li></ul></ul><ul><ul><li>Dysmenorrhea </li></ul></ul><ul><ul><li>Low back pain </li></ul></ul><ul><li>Postoperative TENS </li></ul>
  34. 34. TENS <ul><li>Advantages </li></ul><ul><ul><li>1. Portable </li></ul></ul><ul><ul><ul><li>a. Can be used during activity </li></ul></ul></ul><ul><ul><li>2. Self-treatment </li></ul></ul><ul><ul><li>3. Alternative to cold during cryokinetics </li></ul></ul><ul><li>Disadvantages </li></ul><ul><ul><li>1. Eliminates pain; not cause of pain </li></ul></ul><ul><ul><li>2. May mask more serious problems </li></ul></ul><ul><ul><li>3. We don't know enough about it yet </li></ul></ul><ul><ul><li>4. May become a panacea (too reliant on it, maybe even after healthy) </li></ul></ul>
  35. 35. TENS: Indications & Contraindications <ul><li>Indications </li></ul><ul><ul><li>1. Pain of peripheral origin </li></ul></ul><ul><ul><li>2. Acute pain </li></ul></ul><ul><ul><li>3. Chronic pain </li></ul></ul><ul><li>Contraindications </li></ul><ul><ul><li>1. Do not use on person with: </li></ul></ul><ul><ul><ul><li>a. An implanted pacemaker </li></ul></ul></ul><ul><ul><ul><li>b. History of heart disease </li></ul></ul></ul><ul><ul><li>2. Do not treat trans-thoracic area </li></ul></ul><ul><ul><li>3. Discontinue use if a skin irritation develops </li></ul></ul>
  36. 36. TENS: Precautions <ul><li>G. Precautions </li></ul><ul><ul><li>1. Treatment over an area with: </li></ul></ul><ul><ul><ul><li>a. Impaired sensation </li></ul></ul></ul><ul><ul><ul><li>b. Skin lesions (cuts, abrasions, new skin, recent scar tissue) </li></ul></ul></ul><ul><ul><li>2. While driving or operating heavy machinery </li></ul></ul><ul><ul><li>3. Temporary decrease in pain does not mean cause of pain has gone. </li></ul></ul><ul><ul><li>4. Delicate unit, not a cheap radio </li></ul></ul><ul><ul><ul><li>a. Treat it kindly. </li></ul></ul></ul>
  37. 37. Electrode placement techniques for TENS <ul><ul><li>Electrode placement </li></ul></ul><ul><ul><ul><li>a. Over acupuncture or trigger points </li></ul></ul></ul><ul><ul><ul><li>b. Directly over the pain </li></ul></ul></ul><ul><ul><ul><li>c. Proximal or distal to pain </li></ul></ul></ul><ul><ul><ul><li>d. Crisscross over pain (two-channel unit) </li></ul></ul></ul><ul><ul><ul><li>e. Over motor point (helps with spasms) </li></ul></ul></ul><ul><ul><ul><li>f. Dermatome placement </li></ul></ul></ul>
  38. 38. <ul><li>Adjust pulse width and rate </li></ul><ul><ul><li>a. Go through entire range and select most comfortable </li></ul></ul><ul><ul><li>settings. </li></ul></ul><ul><ul><li>b. Specific settings for specific conditions. </li></ul></ul><ul><ul><ul><li>i. Acute pain: narrow pulse width (75 µsec) and high pulse rate (80 – 200 pps) </li></ul></ul></ul><ul><ul><ul><li>a) Pain relief is almost immediate, but short lasting (1 – 60 min) </li></ul></ul></ul><ul><ul><ul><li>ii. Chronic pain: wide pulse width (200 µsec) and low pulse </li></ul></ul></ul><ul><ul><ul><li>rate (1 – 5 pps) </li></ul></ul></ul><ul><ul><ul><li>a) Pain relief may take ½ hr but will be long lasting (6 – 7 hr) </li></ul></ul></ul>Application Parameters: TENS
  39. 39. <ul><li>Length of application </li></ul><ul><ul><li>1. Extremely variable </li></ul></ul><ul><ul><li>2. Some treat for 30 – 60 min, others for hours </li></ul></ul><ul><li>Frequency of application </li></ul><ul><ul><li>1. Three or four times a day as needed for pain </li></ul></ul><ul><li>Duration of therapy </li></ul><ul><li>1. Use until TENS is no longer effective. </li></ul>Application Parameters: TENS (cont.)
  40. 40. Interferential Current <ul><li>Interference or superimposition of two separate medium-frequency sinusoidal currents on one another </li></ul><ul><li>Symmetrical, sinusoidal, medium frequency (2000 – 5000 Hz) AC </li></ul><ul><li>Invented in 1950; used in United States by 1980s </li></ul><ul><li>Fifth most frequently used physical agent </li></ul>
  41. 41. <ul><li>Basic principle </li></ul><ul><ul><li>Decrease tissue impedance (resistance) so simulation is less painful </li></ul></ul><ul><ul><ul><li>Impedance at 50Hz = ~3200 Ω </li></ul></ul></ul><ul><ul><ul><li>Impedance at 4000 Hz = ~40 Ω </li></ul></ul></ul><ul><ul><ul><li>Current passes more easily through skin </li></ul></ul></ul><ul><li>Advantages of vector pattern </li></ul><ul><ul><li>Surface and deep stimulation </li></ul></ul><ul><ul><li>Targeted tissues for added benefit </li></ul></ul><ul><ul><li>Treatment of easily localized pain </li></ul></ul><ul><ul><li>Treatment of large areas </li></ul></ul><ul><ul><li>Treatment of poorly defined pain </li></ul></ul>What Is IFC Therapy? (cont.)
  42. 42. How Does IFC work? (cont.) <ul><li>Example: One channel runs at 5000 Hz another at 5100 Hz </li></ul><ul><ul><li>Use a dynamic vector (or scan for poorly defined pain) </li></ul></ul><ul><ul><li>Use target for easily localized pain </li></ul></ul><ul><ul><li>Treats most of the area bracketed by the electrodes (scan or dynamic vector) </li></ul></ul>
  43. 43. Is IFC Therapy Effective? (cont.) <ul><li>Those who have had success </li></ul><ul><ul><li>Correctly position vector </li></ul></ul><ul><ul><li>Use appropriate size and positioning of electrodes </li></ul></ul><ul><ul><li>Use appropriate stimulation parameters </li></ul></ul><ul><ul><li>Persevere, if pain relief is not immediately obtained </li></ul></ul>
  44. 44. IFC advantages & disadvantages <ul><li>Advantages </li></ul><ul><ul><li>1. More comfortable than a TENS </li></ul></ul><ul><ul><ul><li>a. Medium-frequency currents meet with less skin resistance than low frequency currents. </li></ul></ul></ul><ul><ul><ul><ul><li>i. TENS uses low frequency currents </li></ul></ul></ul></ul><ul><ul><li>2. Stimulates tissues deeper than a </li></ul></ul><ul><ul><li>TENS unit </li></ul></ul><ul><ul><li>3. Larger coverage area than TENS </li></ul></ul><ul><li>Disadvantages </li></ul><ul><ul><li>1. Eliminates pain; doesn't deal with </li></ul></ul><ul><ul><li>cause of the pain </li></ul></ul><ul><ul><li>2. May mask more serious problems </li></ul></ul><ul><ul><li>3. Few portable units available </li></ul></ul><ul><ul><li>4. Sometimes becomes a panacea </li></ul></ul>
  45. 45. IFC: Indications & Contraindications <ul><li>Indications </li></ul><ul><ul><li>1. Acute pain </li></ul></ul><ul><ul><li>2. Chronic pain </li></ul></ul><ul><ul><li>3. Muscle spasm </li></ul></ul><ul><ul><li>4. Pain that covers a large area </li></ul></ul><ul><li>Contraindications </li></ul><ul><ul><li>1. Do not use on a person who has: </li></ul></ul><ul><ul><ul><li>a. Implanted pacemaker </li></ul></ul></ul><ul><ul><ul><li>b. History of heart disease </li></ul></ul></ul><ul><ul><li>2. Do not treat transthoracic area </li></ul></ul><ul><ul><li>3. Discontinue if skin irritation develops </li></ul></ul>
  46. 46. IFC Precautions <ul><li>Precautions </li></ul><ul><ul><li>1. Be cautious when using IFC over: </li></ul></ul><ul><ul><ul><li>a. Impaired sensation </li></ul></ul></ul><ul><ul><ul><li>b. Skin lesions (cuts, abrasions, new skin, recent scar tissue, etc.) </li></ul></ul></ul><ul><ul><li>2. Use caution when using IFC while driving or operating heavy machinery. </li></ul></ul><ul><ul><li>3. A temporary decrease in pain does not mean the cause of the pain has gone. </li></ul></ul>
  47. 47. Application Parameters: IFC <ul><ul><li>Adjust pulse rate settings for specific injury </li></ul></ul><ul><ul><li> a. For acute pain </li></ul></ul><ul><ul><ul><ul><li>i. Use a high pulse rate of 80 – 200 pps </li></ul></ul></ul></ul><ul><ul><ul><ul><li>ii. Pain relief is almost immediate </li></ul></ul></ul></ul><ul><ul><ul><ul><li>iii. Lasts only a few minutes to 1 hr </li></ul></ul></ul></ul><ul><ul><ul><li>b. For chronic pain </li></ul></ul></ul><ul><ul><ul><ul><li>i. Use a low pulse rate of 1 – 5 pps </li></ul></ul></ul></ul><ul><ul><ul><ul><li>ii. Pain relief may take ½ hr </li></ul></ul></ul></ul><ul><ul><ul><ul><li>iii. May last 6 – 7 hr </li></ul></ul></ul></ul><ul><ul><li>Target or vector </li></ul></ul><ul><ul><ul><li>a. Pain that is easily identifiable and pinpointed </li></ul></ul></ul><ul><ul><ul><ul><li>i. Use target or vector buttons to move spot </li></ul></ul></ul></ul><ul><ul><ul><ul><li>where current intersects to area directly </li></ul></ul></ul></ul><ul><ul><ul><ul><li>over pain </li></ul></ul></ul></ul><ul><ul><ul><li>b. Pain that is hard to pinpoint </li></ul></ul></ul><ul><ul><ul><ul><li>i. Use dynamic vector </li></ul></ul></ul></ul>
  48. 48. Application Parameters: IFC (cont.) <ul><li>C. Length of application </li></ul><ul><ul><li>1. 20 – 30 min </li></ul></ul><ul><li>D. Frequency of application </li></ul><ul><ul><li>1. Once or twice daily, as needed for pain </li></ul></ul><ul><li>E. Duration of therapy </li></ul><ul><li>1. Use until IFC is no longer effective. </li></ul>
  49. 49. NeuroMuscular Electrical Stimulation <ul><li>NMES is used for </li></ul><ul><ul><li>Muscle reeducation and prevention of disuse atrophy </li></ul></ul><ul><ul><li>Decreasing muscle spasm </li></ul></ul><ul><ul><li>Decreasing edema </li></ul></ul>
  50. 50. History of NMES <ul><li>1980 companies started manufacturing Russian current </li></ul><ul><li>No North American scientist has been able to duplicate Kots’s claims of 30% increase in force vs. voluntary contractions and lasting gains up to 40% in healthy athletes </li></ul><ul><ul><li>Great amount of pain (as the current amplitude was increased to try to replicate a voluntary muscle contraction) </li></ul></ul>
  51. 51. Why NMES? <ul><li>Used on patients who cannot perform a voluntary muscle contraction </li></ul><ul><ul><li>Peripheral nerve innervation is intact, yet muscle is too weak to contract from atrophy, pain, immobilization, etc. </li></ul></ul><ul><li>Promotes early AROM in postsurgical and immobilized limbs </li></ul><ul><li>Break pain-spasm-pain cycle of muscle spasms </li></ul>
  52. 52. Don’t Replace Strength Training with NMES <ul><li>NMES recruits fibers in the opposite order than that of a voluntary contraction. </li></ul><ul><ul><li>Machine = large fibers followed by small </li></ul></ul><ul><ul><li>Voluntary = small fibers followed by large </li></ul></ul><ul><li>Patient needs to move on to more traditional weight training ASAP. </li></ul>
  53. 53. Tetanic Contraction to break Muscle Spasm <ul><li>Goals </li></ul><ul><ul><li>Increase local circulation </li></ul></ul><ul><ul><li>Remove metabolic wastes </li></ul></ul><ul><ul><li>Mechanically stimulate muscle fibers </li></ul></ul><ul><ul><li>Induce some muscle spasm fatigue </li></ul></ul>
  54. 54. NMES for Decreasing Edema <ul><li>Produce cyclic muscle contractions to help pump chronic edema </li></ul><ul><ul><li>5 – 10 sec on; 5 – 10 sec off </li></ul></ul>
  55. 55. NMES Effects <ul><li>Effects </li></ul><ul><ul><li>1. Muscle contraction </li></ul></ul><ul><ul><ul><li>a. Increase blood flow </li></ul></ul></ul><ul><ul><ul><li>b. Retard atrophy development </li></ul></ul></ul><ul><ul><ul><li>c. Decrease and retard neuromuscular </li></ul></ul></ul><ul><ul><ul><li>inhibitions </li></ul></ul></ul><ul><ul><ul><li>d. Increase muscle relaxation; decrease </li></ul></ul></ul><ul><ul><ul><li>spasm </li></ul></ul></ul><ul><ul><li>2. Decrease pain </li></ul></ul><ul><ul><ul><li>a. Possibly by decreasing muscle spasm </li></ul></ul></ul>
  56. 56. NMES Advantages & Disadvantages <ul><li>C. Advantages </li></ul><ul><ul><li>1. Can be applied to immobilized body part </li></ul></ul><ul><li>D. Disadvantages </li></ul><ul><ul><li>1. Sometimes becomes a panacea </li></ul></ul>
  57. 57. NMES Indications & Contraindications <ul><li>Indications </li></ul><ul><ul><li>1. Residual or chronic muscle spasm </li></ul></ul><ul><ul><li>2. Any time normal neuromuscular function is not possible </li></ul></ul><ul><ul><li>3. Muscle strains </li></ul></ul><ul><ul><li>4. During cast immobilization or disuse atrophy </li></ul></ul><ul><ul><li>5. Pain owing to muscle spasm </li></ul></ul><ul><li>Contraindications </li></ul><ul><ul><li>1. Do not use: </li></ul></ul><ul><ul><ul><li>a. On a person with a pacemaker </li></ul></ul></ul><ul><ul><ul><li>b. Over the heart or brain </li></ul></ul></ul><ul><ul><ul><li>c. Over recent or non-union fractures </li></ul></ul></ul><ul><ul><ul><li>d. Over potential malignancies </li></ul></ul></ul>
  58. 58. NMES Precautions <ul><li>G. Precautions </li></ul><ul><ul><li>1. Be cautious over an area with : </li></ul></ul><ul><ul><ul><li>a. Impaired sensation </li></ul></ul></ul><ul><ul><ul><li>b. Skin lesions (cuts, abrasions, new skin, </li></ul></ul></ul><ul><ul><ul><li>recent scar tissue) </li></ul></ul></ul><ul><ul><ul><li>c. Decreased range of motion </li></ul></ul></ul><ul><ul><ul><li>d. Extensive torn tissue </li></ul></ul></ul>
  59. 59. Application Parameters: NMES <ul><li>C. Length of application </li></ul><ul><ul><li>1. 10 – 30 min </li></ul></ul><ul><ul><li>2. See individual manufacturer’s instructions. </li></ul></ul><ul><li>D. Frequency of Application </li></ul><ul><ul><li>1. As often as twice per day if separated by 3 – 4 hr </li></ul></ul>
  60. 60. Iontophoresis: Basic Principle <ul><li>Like charges repel like charges, </li></ul><ul><ul><li>Drug ions are repelled or pushed into the underlying tissue. </li></ul></ul><ul><li>Two electrodes </li></ul><ul><ul><li>One drug delivery </li></ul></ul><ul><ul><li>One larger dispersive electrode </li></ul></ul>
  61. 61. How Does Iontophoresis Work? <ul><li>When an electrical DC current is applied </li></ul><ul><ul><li>Positively charged electrode delivers positively charged drug ions into skin and surrounding tissues </li></ul></ul><ul><ul><li>Negatively charged electrode delivers negatively charged drug ions into skin and surrounding tissues </li></ul></ul>
  62. 62. Why Use Iontophoresis ? <ul><li>Delivering medicine such as anti-inflammatories and pain relievers directly without the negative effects of </li></ul><ul><ul><li>Painful needle injections </li></ul></ul><ul><ul><li>Risk of infection from nonsterile needle injections </li></ul></ul><ul><ul><li>Avoid the gastrointestinal side effects of NSAIDs and COX-2 inhibitors </li></ul></ul><ul><ul><li>Localized drug delivery; doesn’t travel through entire system </li></ul></ul><ul><ul><li>Machine is Portable and easy to transport </li></ul></ul>
  63. 63. Common Drug Ions Used in Sports Medicine <ul><li>Dexamethasone </li></ul><ul><ul><li>Negative ion </li></ul></ul><ul><ul><li>Reduces inflammation by inhibiting biosynthesis of prostaglandins and various other inflammatory substances </li></ul></ul><ul><li>Acetate </li></ul><ul><ul><li>Negative ion </li></ul></ul><ul><ul><li>Assists in dissolving calcium deposits and scar tissue in soft tissues </li></ul></ul>
  64. 64. Common Drug Ions Used in Sports Medicine (cont.) <ul><li>Hydrocortisone </li></ul><ul><ul><li>Positive ion </li></ul></ul><ul><ul><li>Assists in decreasing tissue inflammation by inhibiting biosynthesis of prostaglandins </li></ul></ul><ul><li>Lidocaine </li></ul><ul><ul><li>Positive ion </li></ul></ul><ul><ul><li>Assists in decreasing local pain by blocking nerve impulse transmission </li></ul></ul>
  65. 65. Is Iontophoresis Effective? <ul><li>Debate </li></ul><ul><ul><li>Research has shown it to deliver medication from 6 to 20 mm below the skin </li></ul></ul><ul><li>Effective in reducing pain and inflammation associated with </li></ul><ul><ul><ul><li>Plantar fasciitis </li></ul></ul></ul><ul><ul><ul><li>Temporomandibular disorders </li></ul></ul></ul><ul><ul><ul><li>Epicondylitis </li></ul></ul></ul><ul><ul><li>When dexamethasone, lidocaine, or sodium salicylate is used </li></ul></ul>
  66. 66. Ionto Advantages & Disadvantages <ul><li>Advantages </li></ul><ul><li>Compared to injections: </li></ul><ul><ul><li>Virtually painless </li></ul></ul><ul><ul><li>Noninvasive, minimizing… </li></ul></ul><ul><ul><ul><li>Risk of infection </li></ul></ul></ul><ul><ul><ul><li>Risk of tissue necrosis, tendon rupture, etc. </li></ul></ul></ul><ul><li>Compared to oral medications: </li></ul><ul><ul><li>Localized drug delivery, nonsystemic </li></ul></ul><ul><ul><li>Avoid risk of systemic side effects </li></ul></ul><ul><li>Disadvantages </li></ul><ul><ul><li>Eliminates pain or inflammation </li></ul></ul><ul><ul><ul><li>Doesn't deal with the cause of the </li></ul></ul></ul><ul><ul><ul><li>pain/inflammation. </li></ul></ul></ul><ul><ul><li>Slight risk of electrode burns </li></ul></ul><ul><ul><li>Some believe transdermal drug delivery is not possible. </li></ul></ul>
  67. 67. Iontophoresis Indications & Contraindications <ul><li>Indications </li></ul><ul><li>Used to administer water-soluble ionic medications </li></ul><ul><li>Contraindications </li></ul><ul><li>Damaged or denuded skin </li></ul><ul><ul><li>Recent scar tissue </li></ul></ul><ul><li>Drug allergies </li></ul><ul><li>Transcranial </li></ul><ul><li>Orbital region </li></ul><ul><li>Electrically sensitive support systems </li></ul><ul><ul><li>Pacemakers </li></ul></ul>
  68. 68. Iontophoresis: Precautions <ul><li>Precautions </li></ul><ul><li>Diabetes </li></ul><ul><li>Pregnancy </li></ul><ul><li>Over external metal fixation devices </li></ul><ul><li>Elderly skin </li></ul><ul><li>TMJ </li></ul><ul><ul><li>Dizziness </li></ul></ul><ul><ul><li>Metallic taste </li></ul></ul>
  69. 69. Ionto: Drug Dose Calculation <ul><li>Dosage (mA/min) = Current (mA) × Treatment time (min) </li></ul><ul><li>  Examples: </li></ul><ul><ul><ul><li>40 mA/min = 4.0 mA (current) × 10 min (time) </li></ul></ul></ul><ul><ul><ul><li>40 mA/min = 2.0 mA (current) × 20 min (time) </li></ul></ul></ul><ul><ul><ul><li>24 mA/min = 2.0 mA (current) x 12 min (time) </li></ul></ul></ul>
  70. 70. Reported Sensation of Iontophoresis <ul><li>Some patients feel little or no sensation; others describe it as a tingling or warm sensation. </li></ul><ul><li>The intensity of the sensation varies among patients and depends on the site being treated. </li></ul><ul><li>These sensations usually decrease or disappear after a few minutes. </li></ul>
  71. 71. Typical Skin Reactions to Ionto <ul><li>DC causes capillary dilatation, leading to erythema (reddening) of the skin under one or both electrodes. </li></ul><ul><li>Less frequent: appearance of small fluid-filled bumps caused by the release of histamine from dermal mast cells </li></ul><ul><ul><li>Note: These skin reactions disappear over the course of a few minutes but may last longer in patients with particularly sensitive skin. Also, some patients with sensitive skin may react to the adhesive on the electrode. </li></ul></ul>
  72. 72. Reduce Negative Effects from Iontophoresis <ul><li>To help reduce the risk of skin irritation </li></ul><ul><ul><li>Clean the skin with an alcohol scrub. </li></ul></ul><ul><ul><li>After treatment, apply a lotion containing aloe vera. </li></ul></ul><ul><ul><li>Increase the size of the anode or cathode to decrease current density. </li></ul></ul><ul><ul><li>Increase the spacing between electrodes to decrease current intensity. </li></ul></ul>
  73. 73. Application Parameters: Ionophoresis <ul><li>C. Length of application </li></ul><ul><ul><li>1. Dose specific </li></ul></ul><ul><li>D. Frequency of application </li></ul><ul><ul><li>1. Every other day </li></ul></ul><ul><li>E. Duration of application </li></ul><ul><ul><li>1. Up to 3 weeks </li></ul></ul>
  74. 74. High Voltage Pulsed Current Stimulation for Wound Healing <ul><li>Electrical stimulation for the purpose of repairing tissues includes management of open wounds and edema reduction. </li></ul><ul><li>Production of a twin-peak, monophasic, pulsed current driven by its characteristically high electromotive force or voltage </li></ul><ul><li>Positive or negative polarity </li></ul>
  75. 75. HVPC (cont.) <ul><li>Versatile and can perform several functions: </li></ul><ul><ul><li>Pain modulation </li></ul></ul><ul><ul><li>Edema reduction </li></ul></ul><ul><ul><li>Muscle reeducation and spasm reduction </li></ul></ul><ul><ul><li>Wound healing </li></ul></ul>
  76. 76. Characteristics of High-Volt Stimulator <ul><li>Low volt stimulators generate <150 V </li></ul><ul><li>High volt stimulators generate >150 V </li></ul><ul><li>HVPC uses between 150 and 500 V. </li></ul><ul><li>High peak voltages </li></ul><ul><li>Low average current </li></ul><ul><li>Twin peak monophasic waveform </li></ul><ul><ul><li>Resembles a double spike with a fast rise followed by a fast decline </li></ul></ul><ul><li>Short pulse widths (100 – 200 µ sec) </li></ul><ul><li>Pulse rates of 1 – 200 Hz </li></ul>
  77. 77. HVPC: Uses & Techniques <ul><li>Monophasic current used for </li></ul><ul><ul><li>Pain reduction </li></ul></ul><ul><ul><li>Disuse atrophy </li></ul></ul><ul><ul><li>Reduction of edema </li></ul></ul><ul><ul><li>Wound management </li></ul></ul><ul><li>Monopolar or bipolar technique </li></ul><ul><ul><li>Monopolar used when treatment is directed over a large area </li></ul></ul><ul><ul><li>Bipolar used for muscle contraction or chronic pain </li></ul></ul>
  78. 78. HVPC: Advantages <ul><li>Less resistance to the current by the skin </li></ul><ul><li>Short phase duration allows for moderately high-intensity muscle contraction with little discomfort </li></ul><ul><ul><li>Other types of stimulators provide a stronger contraction </li></ul></ul><ul><li>Highly variable in its functions </li></ul><ul><li>Can be used for </li></ul><ul><ul><li>Pain modulation </li></ul></ul><ul><ul><ul><li>a. Sensory level (acute pain) </li></ul></ul></ul><ul><ul><ul><li>b. Motor level (chronic pain) </li></ul></ul></ul><ul><ul><li>Edema reduction </li></ul></ul><ul><ul><li>Treating muscle weakness </li></ul></ul><ul><ul><li>Wound healing </li></ul></ul>
  79. 79. HPVC: Disadvantages <ul><li>Disadvantages </li></ul><ul><ul><li>Cannot provide as strong of a contraction as NMES </li></ul></ul><ul><ul><li>Many aren’t portable. </li></ul></ul><ul><ul><li>Sometimes trial and error are needed to determine electrode polarity for wound healing. </li></ul></ul><ul><ul><li>Effects (muscle contraction) are as strong as low-volt units. </li></ul></ul>
  80. 80. HPVC: Indications & Contraindications <ul><li>Indications </li></ul><ul><ul><li>Wound lesions (pressure sores, scarring from incisions) </li></ul></ul><ul><ul><li>Edema control and reduction </li></ul></ul><ul><ul><li>Residual or chronic muscle spasm (when low-volt unit unavailable) </li></ul></ul><ul><ul><li>Pain </li></ul></ul><ul><li>Contraindications </li></ul><ul><ul><li>Do not use on patient with pacemaker </li></ul></ul><ul><ul><li>Do not use over </li></ul></ul><ul><ul><ul><li>Heart or brain </li></ul></ul></ul><ul><ul><ul><li>Lumbar and abdominal area of pregnant women </li></ul></ul></ul><ul><ul><ul><li>Potential malignancies </li></ul></ul></ul><ul><ul><ul><li>Anterior cervical area </li></ul></ul></ul>
  81. 81. HPVC Precautions <ul><li>G. Precautions </li></ul><ul><ul><li>1. Be cautious when using HVPC over an area with: </li></ul></ul><ul><ul><ul><li>a. Impaired sensation </li></ul></ul></ul><ul><ul><ul><li>b. Extensive torn tissue </li></ul></ul></ul><ul><ul><ul><li>c. Hemorrhagic area </li></ul></ul></ul><ul><ul><li>2. Patients with epilepsy should be monitored during treatment. </li></ul></ul>
  82. 82. HVPC: Edema Management <ul><li>Curbing edema formation </li></ul><ul><ul><li>HVPC is not DC </li></ul></ul><ul><ul><li>Decreases the permeability of microvessels </li></ul></ul><ul><ul><li>Decreases the leaking of vessels, reducing the number of plasma proteins and amount of fluid that leave the vessels to enter the interstitial spaces </li></ul></ul>
  83. 83. HVPC: Edema Management (cont.) <ul><li>Two protocols for curbing edema </li></ul><ul><li>Water immersion </li></ul><ul><ul><ul><li>-Negative polarity </li></ul></ul></ul><ul><ul><ul><li>-120 pps </li></ul></ul></ul><ul><ul><ul><li>-90% of visible motor threshold </li></ul></ul></ul><ul><ul><ul><li>-30 min treatments every 4 hr </li></ul></ul></ul><ul><ul><ul><li>-Apply ASAP postinjury or as long as edema is still forming </li></ul></ul></ul><ul><li>Resolution of edema once formed </li></ul><ul><ul><li>-Can be employed in a muscle pumping action to get rid of edema </li></ul></ul><ul><ul><li>-Intensity increased until strong muscle contraction </li></ul></ul><ul><ul><li>-Setting of 1 – 10 pps for muscle contraction </li></ul></ul>
  84. 84. HVPC: Pain Modulation <ul><li>Ineffective in reducing the pain of delayed-onset muscle soreness </li></ul><ul><li>Yet has been shown to help relieve pain caused by muscle spasm </li></ul>
  85. 85. HVPC: Wound Management <ul><li>How does HVPC stimulate wound repair? </li></ul><ul><ul><li>Body possesses bioelectric currents in the vascular and interstitial tissues. </li></ul></ul><ul><ul><li>Blood vessel walls, insulating tissue matrix, interstitial fluid, and intravascular plasma are capable of conducting bioelectricity. </li></ul></ul><ul><ul><li>When tissues are damaged, an electrical potential is created between injured and noninjured tissues. </li></ul></ul>
  86. 86. HVPC: Wound Management (cont.) <ul><li>DC may stimulate cellular activity when injured. </li></ul><ul><li>Stimulating d é bridement of injured tissues </li></ul><ul><li>Tissue regeneration and remodeling </li></ul><ul><li>May speed up healing by promoting the natural healing process </li></ul><ul><li>May develop a difference in potential between wound area and the surrounding healthy tissue </li></ul><ul><li>Injury potential typically becomes positive 24 – 48 hr after injury & negative 8 – 9 days after injury. </li></ul><ul><li>As the wound heals, the difference slowly returns to baseline. </li></ul><ul><ul><li>Can be used to enhance the natural process of tissue recovery and healing </li></ul></ul>
  87. 87. HVPC: Electrode Polarity <ul><li>Negative polarity </li></ul><ul><ul><li>Increases </li></ul></ul><ul><ul><ul><li>Vascularity </li></ul></ul></ul><ul><ul><ul><li>Stimulation of fibroblastic growth </li></ul></ul></ul><ul><ul><ul><li>Collagen production </li></ul></ul></ul><ul><ul><ul><li>Epidermal cell migration </li></ul></ul></ul><ul><ul><li>Inhibits bacterial growth </li></ul></ul><ul><li>Positive polarity </li></ul><ul><ul><li>Increases macrophages </li></ul></ul><ul><ul><li>Promotes epithelial growth </li></ul></ul>
  88. 88. HVPC: Electrode Polarity (cont.) <ul><li>Most treatments begin with the negative polarity </li></ul><ul><ul><li>Encourages blood clots to dissolve and increases the inflammatory by products </li></ul></ul><ul><ul><ul><li>Necrotic tissues </li></ul></ul></ul><ul><li>Positive polarity encourages clot formation around the wound and granulation tissue. </li></ul>
  89. 89. Application Parameters: HVPC <ul><li>D. Frequency of application </li></ul><ul><ul><li>1. As often as three per day if separated by 3 – 4 hr </li></ul></ul>
  90. 90. Microcurrent Electrical Nerve Stimulation <ul><li>Therapeutic use of constant (DC) and pulsed (interrupted) currents where the stimulus amplitude is in the microamperage range </li></ul><ul><li>Proposed Uses </li></ul><ul><ul><li>Tissue healing </li></ul></ul><ul><ul><li>Pain control </li></ul></ul><ul><ul><li>Edema control </li></ul></ul><ul><ul><li>Slow healing skin lesions </li></ul></ul>
  91. 91. MENS Names <ul><li>Many names of microcurrent </li></ul><ul><ul><li>MENS does not accurately describe this device. </li></ul></ul><ul><ul><li>Current intensity is too low (<1 mA) to cause motor nerve depolarization </li></ul></ul><ul><li>Other than MENS, these devices have been referred to as: </li></ul><ul><ul><li>Low-voltage pulsed microamp stimulation </li></ul></ul><ul><ul><li>Biostimulation </li></ul></ul><ul><ul><li>Bioelectric therapy </li></ul></ul><ul><ul><li>Low-intensity direct current </li></ul></ul><ul><ul><li>Low-intensity electrical stimulation </li></ul></ul>
  92. 92. MENS: Theory <ul><li>Brief research </li></ul><ul><ul><li>No clear-cut research supporting the use of microcurrent therapy </li></ul></ul><ul><ul><li>Positive effect in treating </li></ul></ul><ul><ul><ul><li>Pressure ulcers </li></ul></ul></ul><ul><ul><ul><li>Diabetic ulcers </li></ul></ul></ul><ul><ul><ul><li>TMJ disorders </li></ul></ul></ul><ul><li>No effect in treating </li></ul><ul><ul><li>DOMS </li></ul></ul><ul><ul><li>Pressure ulcers </li></ul></ul><ul><ul><li>Coracoacromial arch pain </li></ul></ul><ul><ul><li>Surgically induced wounds </li></ul></ul>
  93. 93. MENS: Theory (cont.) <ul><li>Might play a positive role in wound healing, an area athletic trainers typically don’t deal with </li></ul><ul><li>It is safe. </li></ul>

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