This document provides an overview of various physical modalities used in physical medicine and rehabilitation, including electrotherapy, light therapy, and acupuncture. It discusses the physiological basis and protocols for transcutaneous electrical nerve stimulation (TENS), interferential current therapy, neuromuscular electrical stimulation (NMES), functional electrical stimulation (FES), ultraviolet light therapy, low-level laser therapy, and acupuncture. Benefits are described for reducing pain and improving muscle function. Precautions and contraindications are also outlined to safely administer each modality.

1. Physical modalities (except heat
and cold )
MODERATOR:
• Dr Ganesh Yadav
Associate Prof
DEPT OF PMR
KGMU
PRESENTED BY:
• Dr Joe Antony
JR1
DEPT OF PMR
KGMU

2. Contents
• Electro therapy
• PHYSIOLOGICAL BASIS
• TENS
• INTERFERENTIAL
• NMES
• FES
• LIGHT THERAPY
• ULTRAVIOLET
• LASER
• ACUPUNTCTURE

3. Electro therapy
• Historical aspect
– Ancient egyptians used electric eels
– Leyden jar invented in 1745 –first medical electrical
stimulation device
– Transcutaneous electrical nerve stimulation (TENS)
devices have been around since the late nineteenth
century
– Melzack and Wall’s gate control theory of pain was
published in 1965,142 which triggered a revival of interest
in the medical community for the use of
electrotherapy in treating pain

4. Physiology
1. Segmental inhibition of pain signals to the
brain and the dorsal horn of the spinal
cord (Melzack and Wall’s gate control
theory)
2. Activation of descending inhibitory
pathways and stimulation of the release
of endogenous opioids and other
neurotransmitters such as serotonin,
gammaaminobutyric acid, noradrenaline,
and acetylcholine.

6. TENS
• Transcutaneous Electrical Nerve Stimulation
– Used for Pain control
• 3 theories of how TENS may control pain
– Gate control theory – high frequency TENS
– Opiate-mediated control – low frequency TENS
– Placebo effect is 30-35 percentage

8. TENS
• TENS devices are small, widely used,
portable (usually battery operated) units
that deliver electric current to the skin
through surface electrodes.
• After education in its use is provided
(usually by a physical therapist) to the
patient, the device is self-administered by
the patient as instructed

9. • commonly used TENS units provide
– conventional or traditional TENS (frequency
greater than 50 Hz)
• Tingling sensation to patient
– low-frequency acupuncture-like TENS
(frequency of 1 to 10 Hz)
• Pricking or burning sensation

10. Protocol
• Treatment time with TENS is normally 30
minutes to 1 hour per session
• With a maximum of 2 hours per session,
for a total of 8 hours per day.
• The treatments are continued for 3 weeks
and gradually reduced over 8 to 12 weeks.

11. Types of stimulators
Conventional
• High-frequency, low-intensity
stimulation—most effective
type of stimulation.
• Duration of treatment: 30
minutes to hours.
• Amplitude is adjusted to produce
minimal sensory discomfort.
• Pain relief begins in 10 to 15
minutes and stops shortly after
removing stimulation.
• Useful for neuropathic pain.
Acupuncture
• Low-frequency, high-intensity
stimulation.
• Duration: 30 to 60 minutes.
• Amplitude high enough to
produce muscle contraction.
• Onset of pain relief can be
delayed several hours.
• Pain relief persists hours after
removing stimulation.
• Useful for acute musculoskeletal
conditions.

12. Hyperstimulation
• High-frequency, high-
intensity stimulation.
• Duration: Rarely tolerated
more than 15 to 30
minutes
• It is considered that this
mode stimulates C-fibers
and causes
counterirritation
Pulse (Burst) Mode
• High-frequency stimulation
bursts at low-frequency
intervals.
• Duration: 30 to 60 minutes.
• Delayed onset of pain relief.
Modulated
• Impulses vary in intensity and
frequency.
• Attempts to avoid neuro-
habituation.

14. • Indications
– Chronic pain
– Chronic low back pain
– Painful diabetic polyneuropathy
– Myofascial pain syndrome
– As an adjunctive to botulinum toxin injection
for adult spasticity
– Spasticity reduction following TENS use has
been reported for patients with stroke, spinal
cord injury, and multiple sclerosis
– benefits in labor, pregnancy-related low back
pain, and dysmenorrhea

15. Precautions and adverse effects
• Contact dermatits
– Change of elctrode
• Higher current passed due to damaged
electrode
– Uncomfortable sensation
• Pacemakers
– Usually resistent

16. Interferential current therapy
• Interferential current
(IFC) therapy is a
type of electrotherapy
modality that uses
alternating medium-
frequency electric
current (4000 Hz)
signals of slightly
different frequencies.

17. • The purported advantage of IFC therapy
over low-frequency TENS devices is the
ability of IFC to decrease skin impedance,
there by penetrating tissue more easily.

18. • Amplitude can be fixed or modulated so
that the point of maximum amplitude
interference changes.
• Can generate a low-frequency current
deep within the treatment area resulting
from its amplitude-modulated parameters

19. • IFC machines come with two, four, or six
applicators that can be arranged in the
same plane (planar) or in different planes
(coplanar)

20. Iontophoresis
• Iontophoresis – use of direct current to
enhance transcutaneous administration of
ionizable substances.
• “an injection without the needle.”
• To produce this effect, a positive and
negative charge is applied to the skin to
administer a drug transdermally
• Most commonly used:
– Dexamethasone, lignocaine
• Conditions:
– Epicondylitis, tendonitis

22. • Lidocaine iontophoresis (1% to 4%
lidocaine, with or without epinephrine, at
20- to 80-mA/min dose applied for 5 to 10
minutes)
– to mitigate pain during needle insertion
procedures such as arterial or venous
cannulation.
• Pretreatment with iontophoresis has also
been shown to significantly reduce pain
associated with needle electromyography.

23. Neuro Muscular Electrical
Stimulation (NMES)
• NMES refers to the process of applying electrical
stimulation above the motor threshold to cause a muscle
contraction.
• Successful use of NMES requires that the alpha
motor neuron is intact.
• NMES systems utilize either external (most common) or
internal electrodes to stimulate the muscle.
• NMES can be utilized as therapeutic muscle stimulation
or for functional electrical stimulation (FES)

24. Systems used
1.External (most common):
Transcutaneous (surface) electrodes
– Typical external systems use stimulation
frequencies of 10 to 50 Hz.
2. Internal: Implantable systems that use
percutaneous, intramuscular, epineural,
intraneural, and intraspinal electrodes

25. Therapeutic Neuromuscular
Electrical Stimulation
• Repetitive stimulation is applied to
paralyzed muscles to minimize atrophy
and/or maintain range of motion.

26. Functional Electrical Stimulation
(FES)
• FES – the use of e-stim to produce limb
movements important for ADL can be
considered FES.
• Ex- stimulation of quadratus lumborum
can help SCI patients sit up in
wheelchair

27. • Open loop systems:
– Feedback is provided manually.
– Stimulation is activated by switches.
– Intensity is adjusted based on response.
– Example: Therapist triggers a heel switch to activate anterior tibialis
during gait cycle.
• Closed loop systems:
– Functional neuromuscular stimulation (FNS): Term typically used
to describe FES using these system types..
– More sophisticated system utilizing more complex automated
technology.
– Electrodes are activated by computer-generated patterns of
stimulation to cause functional movement.
– Feedback provided automatically through movement sensors.

28. Functional Electrical Stimulation (FES)
• Parastep.
– May not get very far due to fatigue.
– Patients may find it easier to get around in the
wheelchair.

29. Muscle fatigue with NMES
Tibialis anterior
Vs.
Quadriceps femoris

30. Functional Electrical Stimulation (FES)
• In SCI patients, e-stim has been shown to:
– Evoke training responses like:
• Increase VO2
• Increase muscle mass
• Improve muscle endurance

31. • Strengthens muscles and maintains muscle mass after
immobilization.
• Provides feedback to enhance voluntary muscle control
(neuromuscular re-education).
• Provides cardiovascular conditioning (e.g., FES cycle
ergometer in SCI).
• Prevents complications from immobility, such as deep
vein thrombosis (DVT), disuse atrophy, and
osteoporosis.
• Shoulder subluxation in hemiplegic limb:
Baker and Parker (1986) published positive results
of a protocol that provided external stimulation to the
posterior deltoid and supraspinatus muscles.

32. • Spasticity management:
– Stimulating spastic muscles to cause
fatigue.
– Stimulation to antagonist muscle to produce
reflex inhibition.
– Enhanced responses seen when used in
conjunction with botulinum toxin injections and
intrathecal baclofen (ITB) therapy.
• Specific systems for phrenic nerve pacing
and urinary incontinence.

33. Precautions
• Avoid stimulation over heart, neck, malignancies,
pregnant uterus, or infected areas.
• May interfere with pacemakers.
• Caution with insensate skin (may cause burns).
• Caution with patients with seizure disorder.
• Important to monitor BP when FES is used to exercise the
lower extremities of SCI patients (especially
patients over 45 years old or patients with a history of
cardiovascular disease)

34. NMES to control spasticity
• Reciprocal inhibition – activate the
antagonist and this may produce an
inhibition to the spastic muscle and
therefore reduce spasticity.
• For example
– Spastic plantar flexors.
– Stimulated the tibialis anterior
– 2-3 seconds on/10 seconds off for 30 minutes
– Reduced spasticity for up to 6-14 hours.

35. Benefits
• Electrical stimulation of SCI muscle has
been shown to:
– Increase type IIa fibers
– Increase capillary density
– Increase enzymes of energy supply
– Increase fatigue resistance
– Increase cardio pulmonary endurance

37. LIGHT THERAPY
• ULTRA VIOLET LIGHT
• LOW LEVEL LASER THERAPY

38. ULTRA VIOLET THERAPY
Wavelength of 2000 to 4000 Å. Bactericidal
wavelength is 2537 Å.
• It can be produced by a small, hand-held
mercury or “cold quartz” lamp.
• Produces a nonthermal photochemical
reaction with resultant alteration of DNA
and cell proteins

39. • PHYSIOLOGICAL EFFECTS
–Bactericidal on motile bacteria
– Increased vascularization of
wound margins
– Hyperplasia and exfoliation
– Increased vitamin D production
–Excitation of calcium metabolism
–Tanning
• Indications
– For treatment of aseptic
and septic wounds
– Psoriasis treatment—
utilizes Goeckerman’s
technique, where a coal–
tar ointment is applied to
the skin prior to UV
treatment
– Acne treatment
– Treatment of folliculitis

40. • Precautions
– Fair skin
– Scars, atrophic skin
–Acute renal and hepatic failure
– Severe diabetes
–Hyperthyroidism
–Generalized dermatitis
– Advanced arteriosclerosis
–Active, progressive pulmonary
tuberculosis
– Protect eyes from
conjunctivitis, photokeratitis—
shield from UV rays using
goggles
• Contraindications
– Pellagra
– Porphyria
–Sarcoidosis
– Acute psoriasis
–Lupus
–Eczema
–Herpes simplex
–Xeroderma pigmentosum

41. Low Level Laser Therapy
• LLLT is thought to have a stimulating
effect on target tissues
• used to decrease pain and inflammation
• Stimulate collagen metabolism and wound
healing
• promote fracture healing.
• Exact biomechanical action is still under
investigation

42. • laser probe is usually placed perpendicular to the skin
surface of the target area in a short distance to maximize
the energy transmission.
• For commercial devices, only the treatment time and the
intensity can be adjusted.
• Lack of consensus for the dose, duration, and type of
laser on therapeutic effect leaving treatment
measurements to be determined largely empirically.
• Combining lasers of two different wavelengths is
increasing in popularity

43. Benefits and evidence
• RCTs show pain reduction immediately after treatment in
patients with acute neck pain, and up to 22 weeks after
completion of treatment in those with chronic neck pain
of various etiologies
• Systematic reviews and metaanalysis also show the
effect of LLLT on pain reduction for different joints,
including wrist, fingers, knee, temporomandibular joints,
etc
• Effect on lateral epicondylitis (tennis elbow) is debated
• clinical trials with human models do not provide sufficient
evidence to establish the usefulness of LLLT as an
effective tool in wound care, at present.
Reference - Braddoms,2021 edition

44. Precautions
• few milliwatts of output power can be
hazardous to human eyes if the beam hits
the eye directly or after reflection from a
shiny surface.
• LLLT should not be used in areas with
cancerous tissue.

45. Acupuncture
• Acupuncture is the procedure of inserting
and manipulating filiform needles into
various points (called acupuncture points)
to relieve pain or for other therapeutic
purposes.

46. Possible mechanisms
• the descending and ascending inhibition of
pain (gate theory)
• hormonal mechanism (endorphin
regulation),
• the interaction with the autonomic nervous
system,

47. Types of needling
• Finger Pressing Insertion –
• This technique is used when a
short needle is used. Before
inserting, the practitioner uses
one fingertip (guiding finger) of
the assisting hand to gently
press the acupuncture point.
The needle is then inserted
into the skin of the
acupuncture point along the
edge of the guiding finger.
• Pinching Needle Insertion.
• This technique is used when
an acupuncture point is deep
and a long needle is used.
Once the acupuncture point is
identified, the thumb and index
fingers of the assisting hand
hold the distal part of the
needle with a sterile gauze or
sterile cotton ball, and the
dominant hand holds the
handle of the needle. The
needle is then inserted with
both hands.

48. • Pinching Skin Needle
Insertion. This technique is
used when the skin and
muscles of the inserted site are
thin or if the insertion point is
close to important organs such
as the lungs or eyeballs. Once
the acupuncture point is
identified, the skin and
muscles are pinched or picked
up with the thumb and index
fingers of the assisting hand.
The needle is then inserted
through pinched skin with the
dominant hand
• Tight Skin Needle Insertion.
This technique is used when
the skin over the acupuncture
point is loose. Once the
acupuncture point is identified,
the skin over the acupuncture
point is stretched and
tightened with the thumb and
index fingers. The needle is
inserted with the dominant
hand

49. Conditions which shows
improvement
• facial pain, headache, knee pain,
• lower back pain, neck pain, periarthritis of
the shoulder, postoperative
• pain, rheumatoid arthritis, sciatica, sprain,
stroke, and tennis elbow

50. Thank you