students education purpose

1. A.THANGAMANI RAMALINGAM
PT, MSc (PSY), MIAP

2. Almost 60 yrs old, popular last 25 years
with numerous uses.
Waveform:
• Twin-peak monophasic pulse
• phase duration: 25s, sometimes adjustable
• comfortable but weak current; polarity present but
electrochemical (net DC) effect not harmful.
Typical stimulation time does not exceed 1 hour
• Upto200µs
• Voltage more than 100 volts

3.  Wound healing
 Oedema reduction
 Pain modulation
 NMES
 On vascular system

4. Amplitude (based on desired excitatory
response)
Pulse Rate (related to pain control theory
or motor response needed)
Mode - Continuous, Ramp-Surge,
Alternate

5. Robert Becker – 1962
Theory - “Current of Injury”
• normal bioelectric system,
nonexcitable tissues have a
charge
 skin -----
 deeper tissues +++++
 neuraxis ++++++
 periphery -------
• Wounds - system is disturbed &
creates a “current of injury” that
initiates tissue healing . . .
inflammatory process,
migration of cells, etc..
• Use of E-stim magnifies the
“current of injury” to initiate,
maintain, or speed the process.
 Further research established
• Wound tissue is (+) & skin
around is (-); this difference is
the “skin battery” or “current of
injury” and must exist for proper
healing;
if it fails or is disrupted, then
slow/no healing can occur. E -
stim can help restore the “skin
battery”.
 Further supported by
evidence that many
chronic wounds lost (+)
polarity; e-stim w/ the
anode (+) over the wound
enhanced healing. (using
DC)
 If healing plateaued,
switching polarity = good
outcome

8. Monophasic twin-pulse current (HVPC)
105 pps
Amplitude: submotor
Time - 45 min, 5 days a week
Wound packed with soaked gauze and
anode (+) placed over wound
Cathode placed 15 cm away, proximal
Rationale: Done to amplify the “current of
injury”

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

10. Process can be corrected and/or
enhanced by attraction of cells to the
wound thru use of anode (+) or cathode (-)
• Leukocytes, fibroblasts, endothelial & epithelial
cells, etc.. all have polarity and can be electrically
attracted.
Treatment polarity depends on stage of
the wound

11.  Monophasic twin-pulse current (HVPC)
 100 pps, no mention of pulse width
 Amplitude - just below motor
 Time - 60 min, 5 days a week
 Wound packed with soaked gauze
 Polarity - based on wound state
 Other electrode placed 15 - 20 cm away
(proximal) to complete the circuit
 Done to amplify the “injury potential” or
“current of injury” and produce “galvanotaxic
attraction”

12. Options
• Directly over the wound
• Directly in the wound *
• Straddle the wound
WOUND TREATED
 Burns
 Post surgical wounds
 Hand injuries
 Venous ulcers
 Diabetic ulcers

13. 6µA-1.4mA of DC current stills the growth
of micro organisms.
Current disrupts the homeostatic
mechanism of the organism.
Anodal current
 Cathodal current
Dermal cell movement
Germicidal effect
Sedative effect
Increases blood flow
Germicidal effect
Clumping of leucocytes

14.  Why not use LIDC ??:
Studies have shown it to be
effective
• Much longer Rx time and
greater frequency of Rx
• electrochemical changes
more pronounced &
potentially harmful (due to pH
changes in tissue)
 HVPC has a shorter Rx time
and less frequent, no
harmful electrochemical
changes in the tissue
 Mechanisms by which
biphasic or AC may enhance
healing are not well-
understood.
 ESTR usually not used on
well-healing wounds, more
for chronic wounds
 DOES NOT replace typical
wound care
 Suggest physician
cooperation/agreement
 Patient tolerance or refusal
a potential issue based on
the way you describe it.

15.  Osteomyelitis
 Malignancies / neoplasms
 Carotid sinus / laryngeal ms.
 Thru the thorax
 Demand-type pacemakers
 Over topical agents containing metal ions
(iodine, mercurochrome)
 Others as previously learned; except for open
tissue

16. Negligible thermal& electrochemical effects
Cannot be used to treat denervated
muscles

17.  Electrical stimulation for the treatment of
wounds will only be covered for chronic
Stage III or Stage IV pressure ulcers, arterial
ulcers, diabetic ulcers and venous stasis
ulcers.
 All other uses of electrical stimulation for the
treatment of wounds are non-covered.
 Chronic ulcers are defined as ulcers that
have not healed within 30 days of
occurrence.
 Electrical stimulation will not be covered as
an initial treatment modality.

18.  Electrical stimulation will be covered only after
appropriate standard wound therapy has been
tried for at least 30-days and there are no
measurable signs of healing. This 30-day period
can begin while the wound is acute.
 Measurable signs of improved healing include a
decrease in wound size, either surface area or
volume, decrease in amount of exudates and
decrease in amount of necrotic tissue. Standard
wound care includes: optimization of nutritional
status; debridement by any means to remove
devitalized tissue; maintenance of a clean, moist
bed of granulation tissue with appropriate moist
dressings; and necessary treatment to resolve any
infection that may be present.

19.  Continued treatment with electrical
stimulation is not covered if measurable signs
of healing have not been demonstrated within
any 30-day period of treatment.
 Electrical stimulation must be discontinued
when the wound demonstrates 100 per-cent
epithelialzed wound bed.
 This service can only be covered when
performed by a physician, physical therapist,
or incident to a physician service.

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

21. This treatment is indicated for acute
trauma (sprain, strain, contusion) or post-
surgery. The situation must be an ACUTE
TRAUMATIC CONDITION where
bleeding, swelling & inflammation are
actively developing. The underlying
physiological effect is largely unknown but
studies often point toward an effect upon
capillary permeability - related to
histamine release.

22. STAGE Rx CURRENT Polarity FREQ RESPONSE TIME
ACUTE Control of
Formation
HVPC (--) 120 PPS SUBMOTOR 30 Min/
4 HRS
during
acute
stage
SUBACUTE
I CHRONIC
Reduction HVPC
BIPHASIC
RUSSIAN
N/A Varies:
need ms.
pump
MOTOR 20 min
daily

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

25.  :
 There are five different currents
available for didynamic therapy.
1. DF (Fixed di-phase):
Full-wave rectified alternating current,
with a frequency of 50 Hz.
2. MF (Fixed mono-phase):
Half-wave rectified alternating current,
with a frequency of 50 Hz.
3. CP (Short periods):
I-sec DF I-sec MF I-sec
DF
Equal phases of DF and MF,
alternating without interval pauses.
4. LP (Long periods):
10-sec MF 5-sec DF
10-sec MF
It includes 10-sec phase of MF,
followed by 5-sec phase of DF, in
which peak intensity is varied with
a frequency to rise and then fall.
5. RS (Syncopal Rhythm):
It comprises 1-sec phase of MF,
followed by a 1-sec rest phase.
Physical properties

26. * Pain masking (increase of the stimulation threshold):
By DF current, stimulation of the sensory nerves may
not always cause excitation but it can be altered.
* Vasodilatation and hyperemia: Due to release of
histamine in the tissues. The same can occur in
deeper structures by reflex activity.
* Muscle fibers stimulation: Didynamic current stimulates
the muscle fibers, causing muscle contraction. CP and
LP currents stimulate increase blood flow to the
muscle and reduce edema.
* Stimulation of vibration sense: This leads to central
masking of pain sensation.

27.  Didynamic stimulation causes relief of pain
and edema in the following conditions:
 Soft tissue injury (sprains, strain, contusion
and epicondylitis).
 Joint disorders (post-immobilization and
arthritis).
 Circulatory disorders (Raynaud's disease
and migraine).
 Peripheral nerve disorders (neuralgia and
sciatic neuritis).

28. * Open skin: The current tends to concentrate at this
point; small broken areas can be insulated by
Vaseline.
* Bony areas: It may produce burn.
* Loss of sensation: It can produce burn.
* Skin lesions: Eczema fungi can be irritated and
made worse.
* Infections: It may cause spreading of infection.
* Thrombosis.
* Cardiac pace makers.
* Superficial metal.

29. * Intensity: It should be
increased gradually
until definite vibration
or prickling sensation
occurs.
* Duration: Not more
than 12 minutes; each
type for 3 minutes.
* Frequency: Daily or
every other day for 12
sessions.
 DF: It is used for the initial
treatment and before application of
other currents. The patient feels a
prickling sensation, which subsides
after a short time.
 - MF: The patient feels a strong
vibration for longer time than the
sensation of DF. It is used for
treatment of pain without muscle
spasm.
 - CP: In DF phase, there are fine
tremors in MF phase (strong and
constant vibration). There are
rhythmic contractions, being used
for treatment of traumatic pain.
 - LP: It has a long-lasting analgesic
effect. It is used with combination
of CP in treatment of neuralgia.
 - RS: It can be used for faradic
stimulation of the muscle and as a
test for motor nerve excitability.

30. “low-intensity direct current
that delivers monophasic
or biphasic pulsed
microamperage currents
across the intact surface
of the skin’’
 MET uses currents that are
1/1000th of an ampere smaller
than those delivered by
standard TENS devices
(milliamperes)
 Microcurrent electrical nerve
stimulation
Microamperage stimulation
Low-intensity direct current and
Pulsed low intensity direct
current
 Microcurrenteffect
600 HzSkinSurface
500 HzSkin subSurface
300 HzLymphatic
stimulation
20 HzCirculation
10 HzFacial muscles
0.8 HzDeep facial
 Waveform shapeMicro-
current effect
SineSuperficial
SquarePumping
RectangularLifting
Sawtooth
(Ramp)Longer lifting

31. Specifications
Channels :Dual
Power Source :9V alkaline
battery
Output Voltage :12 volts
Timer :20, 40 min and
constant
Frequency :0.3, 8 and 80Hz

32. Alleviation of
 Pain
 Inflammation
 Spasm
Promotion of
 Healing
 Osteoarthrotis
 Osteoporosis
 Sports injuries
 Fractures
 Wounds and
 Ulcers

33. Sinusoidal currents are evenly alternating
sine wave currents of 50Hz, the form of
the UK mains current (see Fig. 3.4). This
gives 100 pulses or phases in each
second of 10 ms each, 50 in one direction
and 50 in the other. It can be produced
from the mains by reducing the voltage to
60 or 80 V with a step-down
transformer.

36.  Indicated to introduce
ions into the body
using direct current
 Advantages are it’s
painless, sterile,
noninvasive
 Phonophoresis
delivers whole
molecules across the
skin into the body.
 Iontophoresis delivers
ions into the tissues.
 Both are noninvasive
means to delivers
chemicals to the body

37.  Negatively charged
electrons are repelled
from the cathode. Thus
negatively charged
electrons move toward
the positive pole where
they create an acid
reaction.
 Positively charged ions
are attracted to the
negative electrode
creating an alkaline
reaction at the cathode
 Positively charged ions
are driven into tissues
from the positive pole
 Negatively charged ions
are driven into tissues
from the negative pole
 Therefore you must
know the polarity and
match it with the
appropriate electrode

38.  Ion flow is dependent
upon:
• Tissue impedance
• Strength of current field
• Ion migration is caused
by the potential
difference in current
density between the
active and dispersive
electrodes
 Adjusted by:
 1. Intensity
adjustments
 2. Changing the size
of the electrode

39.  Directly related to:
• 1. Intensity of the
current (density at the
active electrode)
• 2. Duration of current
flow
• 3. Concentration of
ions in solution

40.  Low amp more effective
than higher current
intensities
 Higher intensities reduce
effective penetration to
tissues
 Usually between 3-5 ma
 Increase the intensity
slowly- WANT pt to
Report “Prickling” or
“Tingling”
 Pt reports of Burning or
Pain mean STOP!!
 Slowly decrease intensity to
0 when terminating
treatment
 Remove electrodes
 Max current intensity may
be determined by the size of
the active electrode.
 Current amplitude is set so
that the current density falls
between .1-.5ma/cm2
 10-20 minutes
 Average 15
 Check skin every 3-5
minutes

41.  Only use compounds soluble in both fat and
water Penetration <1mm
 Heavy metals tend to become insoluble
precipitates inhibiting their penetration
 Negative ions at anode produce acidic
reaction via formation of HCL.
 Pos ions at the cathode produce alkaline
reactions, forming sodium hydroxide

44. Table 7-1. Recommended Ions for Use By Therapists42
POSITIVE
Antibiotics, gentamycin sulfate (+), 8 mg/mL, for suppurative ear chondritis.
Calcium (+), from calcium chloride, 2% aqueous solution, believed to stabilize the
irritability threshold in either direction, as dictated by the physiologic needs of
the tissues. Effective with spasmodic conditions, tics, and "snapping fingers"
(joints).
Copper (+), from a 2% aqueous solution of copper sulfate crystals; fungicide,
astringent, useful with intranasal conditions, e.g., allergic rhinitis or "hay fever,"
sinusitis, and also dermatophytosis or "athlete's foot."
Hyaluronidase (+), from Wydase crystals in aqueous solution as directed; for
localized edema.
Lidocaine (+), from XYLOCAINE 5% ointment, anesthetic/analgesic, especially
with acute inflammatory conditions (e.g., bursitis, tendinitis, tic doloreux, and
TMJ pain).
Lithium (+), from lithium chloride or carbonate, 2% aqueous solution, effective as
an exchange ion with gouty tophi and hyperuricemia.
Magnesium (+), from magnesium sulfate ("Epsom Salts"), 2% aqueous solution,
an excellent muscle relaxant, good vasodilator, and mild analgesic.
Mecholyl (+), familiar derivative of acetylcholine, 0.25% ointment, is a powerful
vasodilator, good muscle relaxant, and analgesic. Used with discogenic low back
radiculopathies and sympathetic reflex dystrophy.
Priscoline (+), from benzazoline hydrochloride, 2% aqueous solution, reported
effective with indolent ulcers.
Zinc (+), from zinc oxide ointment, 20%, a trace element necessary for healing,
especially effective with open lesions and ulcerations.

45. NEGATIVE
Acetate (-), from acetic acid, 2% aqueous solution; dramatically
effective as a sclerolytic exchange ion with calcific deposits.
Chlorine (-), from sodium chloride, 2% aqueous solution, good
sclerolytic agent. Useful with scar tissue, keloids, and burns.
Citrate (-), from potassium citrate, 2% aqueous solution, reported
effective in rheumatoid arthritis.
Dexamethasone (-), from Decadron, used for treating musculoskeletal
inflammatory conditions.
Iodine (-), from "Iodex" ointment, 4.7%, an excellent sclerolytic agent,
as well as bacteriocidal, fair vasodilator. Used successfully with
adhesive capsulitis ("frozen shoulder"), scars, etc.
Salicylate (-), from "Iodex with methyl salicylate," 4.8% ointment, a
general decongestant, sclerolytic, and anti-inflammatory agent. If
desired without the iodine, may be obtained from MYOFLEX
ointment (trolamine salicylate 10%) or a 2% aqueous solution of
sodium salicylate powder. Used successfully with frozen shoulder,
scar tissue, warts, and other adhesive or edematous conditions.
EITHER
Ringer's solution(+/-), with alternating polarity for open decubitus
lesions.
Tap water (+/-), usually administered with alternating polarity and
sometimes with glycopyrronium bromide in hyperhidrosis.

46.  Analgesia
 Scar modification
 Wound healing
 Edema
 Burns
 RSD
 Inflammatory MS
conditions
 CA++ deposits
 Hyperhidrosis
 M spasm
 Fungi open skin
lesions
 Herpes
 Gout

47.  Skin sensitivity reax
 Sensitivity to agent
 Gastritis/ulcer-
cortisone
 Asthma-mecholyl
 Sensitivity to metal
 Sensitivity to seafood-
iodine
 Recent scars in
treatment area
 Metal implants close
to skin
 Acute injury where
there is still bleeding
 PPM