1. INTERFERENTIAL CURRENT
DR. GRANT

2. 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 that are necessary to produce the standard interferential effect in a patient

3. 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

4. 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.

5. 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).

6. 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.

7. 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.

8. 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.

9. 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.

10. INTERFERENTIAL THERAPY TREATMENT DURATION
However, if the overall treatment program has been carefully designed and delivered , then good results should be expected fairly quickly.

11. 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.

12. 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.

13. 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.

14. 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

15. INTERFERENTIAL THERAPY
I.F. can and should be combined with other modalities except ice and Diathermy.
Combining treatments implies giving two different but complimentary treatments at different times or in some instances at the same time (moist heat)

16. 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.

17. INTERFERENTIAL THERAPY CONTRAINDICATIONS
Pacemakers
Thrombosis
Cardiac Conditions
Bacterial Infections
Malignancy

18. INTERFERENTIAL THERAPY WARNINGS
Pregnancy
Implants of any electrical nature
Transcerebrally
Skin diseases

19. INTERFERENTIAL THERAPY

21. INTERFERENTIAL THERAPY

22. INTERFERENTIAL THERAPY

24. INTERFERENTIAL THERAPY

26. INTERFERENTIAL THERAPY

36. HIGH VOLTAGE THERAPY
DR. GRANT

37. HIGH VOLT THERAPY

38. HIGH VOLT THERAPY

40. COMBINATION THERAPY
DR. GRANT

41. 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.

42. 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.

43. ULTRASOUND AND ESC
Both modalities provide analgesic effects, and both have been shown to be effective in reducing the pain-spasm-pain cycle, although the mechanisms responsible are not clearly understood.

44. ESC & ULTRASOUND

45. CONNECTION IN BACK OF ULTRASOUND

46. BACK OF UNIT CONNECTION

47. BANANA PLUG

54. MEDIUM FREQUENCY

56. QUESTIONS REGARDING COMBINATION THERAPY?

57. Pain Alliance Institute
MICROCURRENT
DR. GRANT
Pain Alliance Institute

58. MICROCURRENT
This type of electrical modality uses an electrical current of less than 1 microA.
They are subthreshold in nature and patients usually do not experience either the tingling sensation or muscle contraction seen with other electrical stimulators.

59. 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.

60. 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.

61. 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.

62. 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.

63. 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.

64. MICRO CURRENT THERAPY
It is suggested that lower pulse rates are used for chronic conditions and higher pulse rates for more acute problems.

65. 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.

66. 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.

67. 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.

69. 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 over-the-counter form of saline.

70. 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)

71. 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.

72. 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

73. 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).

74. MICRO CURRENT THERAPY NERVE ROOT TECHNIQUE
In this method, both probes are used to stimulate adjacent interspinous spaces of involved vertebral segments for seconds.
Significantly enhanced pain control and improved segmental ROM have been reported when using this technique.

75. 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 ROM’s.

76. MICRO CURRENT THERAPY PAD TREATMENT
When pads are used, placement is proximal and distal to the site of involvement.

77. 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, anti-inflammatory, and healing properties

78. 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.

79. 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.

80. MICROCURRENT

81. Pain Alliance Institute
RUSSIAN STIMULATION
DR. GRANT
Pain Alliance Institute

82. RUSSIAN CURRENTS
This class of current generators was developed in Canada and the United States after the Russian scientist Yadou M. Kots presented a seminar on the use of EMS to augment strength gain.
The stimulators developed after this presentation were termed “Russian Current” generators.

83. RUSSIAN CURRENTS
These stimulators have evolved and presently deliver a medium frequency of 2000 to 10,000 Hz polyphasic AC wave form.
The pulse can be varied from 50 to 250 m-sec; the phase duration will be one half of the pulse duration, or 25 to 125 m-sec.

84. RUSSIAN CURRENTS
As the pulse frequency increases, the pulse duration decreases.
There are two basic waveforms: a sine wave and a square wave cycle with a fixed intrapulse interval.
The sine wave is produced in a burst mode that has a 50 percent duty cycle

85. RUSSIAN CURRENTS
According to strength - duration curve data, to obtain the same stimulation effect as the duration of the stimulus decreases, the intensity must be increased.
The intensity associated with this duration of current could be considered as painful.

86. RUSSIAN CURRENTS
To make this intensity of current tolerable, it is generated in 50-burst-per-second envelopes with an interburst interval of 10 m-sec.
This slightly reduces the total current but allows enough of a peak current intensity to stimulate muscle very well.

87. RUSSIAN CURRENTS
The other factor affecting patient comfort is the effect that frequency will have on on the impedance of the tissue.
Higher frequency currents reduce the resistance to the current flow, again making this type of waveform comfortable enough that the patient may tolerate higher intensities.

88. RUSSIAN CURRENTS
As the intensity increases, more motor nerves are stimulated, increasing the magnitude of the contraction.
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.

89. RUSSIAN CURRENTS
The frequency (bursts per second) is also a variable that can be controlled.
This would make the muscle respond with a twitch rather than a gradually increasing mechanical contraction.
Gradually increasing the number of bursts interrupts the mechanical relaxation cycle of the muscle and causes more shortening to take place.

90. RUSSIAN STIMULATION
AC medium frequency 2500 Hz
Primary purpose is for muscle rehab/re-education.

91. RUSSIAN STIMULATION PHYSIOLOGICAL EFFECTS
Muscle strengthening and re-education
Decrease edema
Increase blood flow
Reduces muscle spasm
This would make the muscle respond with a twitch rather than a gradually increasing mechanical contraction.

92. 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 .

93. RUSSIAN STIMULATION INDICATIONS
Chronic back pain
Post-injury muscle atrophy and/or wasting
Post-casting
Muscle spasms

94. RUSSIAN STIMULATION CONTRAINDICATIONS
Pacemakers
Malignant lesions
Upper thorax (anterior)
Pregnancy

95. 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

96. RUSSIAN STIMULATION PAD PLACEMENT
Bipolar technique
Origins and insertions and/or until you see a muscle contraction that is tolerable to the patient.

97. 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.

98. 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.

99. 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.

100. RUSSIAN STIMULATION SUMMARY
Electrically stimulated muscle contractions are used clinically to:
. Help with muscle re-education
. Muscle contraction for muscle pumping action
. Reduction of swelling
. Prevention or retardation of atrophy

101. RUSSIAN STIMULATION SUMMARY
. Muscle strengthening
. Increasing range of motion in tight joints.

102. 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.

103. RUSSIAN STIMULATION 10/10 PRE-SET
Physiological effects are as follows:
. Decrease edema via pumping effect
. Break spasms by fatigue of muscles
. Increase blood flow

104. 10/10 PRE-SET INDICATIONS
Muscle spasms
Edematous situations

105. 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

106. RUSSIAN STIMULATION

107. RUSSIAN STIMULATION

109. BIPHASIC STIMULATION COURSE # 7121
DR. GRANT

110. 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 muscle-stimulating burst is followed by a relaxation (rest) cycle.

111. BIPHASIC THERAPY
There are 3 modes of treatment in Biphasic stimulation:
. Normal
. Reciprocal
. 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.

112. 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.

113. 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)

114. 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.

115. 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

116. BIPHASIC THERAPY
When choosing the Biphasic function, the default settings are automatically selected:
. Normal treatment mode
. 10/30 contraction/rest times
. Ramp up and down time : .5 sec.
Increase the intensity to the patients tolerance
Press start

117. BIPHASIC THERAPY CAUTION
NEVER TURN THE POWER ON OR OFF WHILE THE UNIT IS CONNECTED TO THE PATIENT

118. BIPHASIC STIMULATION

120. LOW POWER LASERS
DR. GRANT

121. LOW POWER LASERS
Lasers can be categorized as either low power, depending on the intensity of energy they deliver.
High power lasers are also known as “hot” lasers because of the thermal responses they generate.

122. LOW POWER LASERS
These are used in the medical realms in numerous areas, including surgical cutting and coagulation, ophthalmologic, dermatologic, oncologic, and vascular specialities.
The use of low power lasers (cold or soft) for wound healing and pain management is a relatively new area of application in medicine.

123. LOW POWER LASERS
These lasers produce a maximal output of less than 1 milliwatt in the United States and work by causing photochemical, rather than thermal, effects.
No tissue warming occurs.
The exact distinction of the power output that delineates a low versus high power laser varies.

124. LOW POWER LASERS
Low power devices are considered any laser that does not generate an appreciable thermal response.
This category can include lasers capable of producing up to 500 watts of power (up to a Class IV laser)

125. LOW POWER LASERS
Low power lasers, which have been studied and used in Europe for the past 20 to 25 years, have been investigated in the United States for the past decade.
The potential application for low power lasers include treatment of tendon and ligament injury, arthritis, edema reduction, soft tissue injury, ulcer and burn care, scar tissue inhibition, and acutherapy

126. LOW POWER LASERS
The helium neon (HeNe) and gallium arsenide (GaAs) lasers are the two principle lasers currently under investigation in the United States for conservative management of medical conditions.

127. HELIUM NEON LASERS
The HeNe gas laser uses a gas mixture of primarily helium with neon in a pressurized tube.
This creates a laser in the red portion of the electromagnetic spectrum with a wavelength 632.8nm
The power output of the HeNe can vary, but typically runs from 1.0 to 10.0mW, depending on the gas density used.

128. HELIUM NEON LASERS
Larger tubes are necessary for higher-power outputs, and each requires a precise power drive to operate.
Laser output can decrease, depending on the care of the equipment, or the number of operating hours, and whether fiberoptics are used.

129. HELIUM NEON LASERS
The HeNe laser in the United States delivers a power output of 1 mW through a fiberoptic tube in a continuous mode.
Although the HeNe laser light is well collimated, the utilization of fiberoptics causes a divervence of the beam from 18 inches to 21 inches.

130. HELIUM NEON LASERS
Fiberoptics can decease the out-put delivery by 50 percent or more as the light travels from the lasing medium to the tip of the applicator.
Fiberoptics are used to make the delivery more convenient because the size of the gas tube would make direct application difficult.

131. HELIUM NEON LASERS
HeNe lasers upt to 6 mW have been manufactured for clinical use in Canada, which has fewer governmental restrictions than the United States.
These higher output lasers, although still considered low power, allow delivery of desired dosages in reduced time.

132. GALLIUM ARSENIDE LASERS
The gallium arsenide (GaAs) laser utilize a diode to produce an infrared (invisable) laser at a wavelength of 904 nm.
Diode lasers are composed of semiconductor silicone materials that are precisely cut and layered.
An electrical source is applied to each side, and lasing action is produced at the junction of the two materials.

133. GALLIUM ARSENIDE LASERS
The cleaved surfaces function as partially reflecting surfaces that will ultimately produce coherent light.
Diode lasers produce a beam that is elliptically shaped so the lasers have a 10 degrees to 35 degrees divergence despite the fact that no fiberoptics are used.

134. GALLIUM ARSENIDE LASERS
The 904 nm is delivered in a pulsed mode because of the heat produced at the junction of the diode chips.
The GaAs laser manufactured in the United States has a peak power of 2 W but is delivered in a pulsed mode that decreases the average power to 0.4 mW output if delivered at 1000Hz.

135. GALLIUM ARSENIDE LASERS
The application of additional layers of materials to other types of diodes allows their operation in a continuous mode at room temperature.
The continuous mode results in higher average power outputs from the lasers.
Higher output diode lasers are manufactured for clinical applications in Canada.

136. GALLIUM ARSENIDE LASERS
The laser units available in the United States have the ability to deliver HeNe and GaAs lasers.
The same device can both measure electrical impedance and deliver electrical point stimulation.
The impedance detector allows hypersensitive or acupuncture points to be located.

137. GALLIUM ARSENIDE LASERS
The point stimulator can be combined with laser application when treating pain.
The electrical stimulation is believed to provide spontaneous pain relief, whereas the laser provides more latent tissue responses.

138. CLINICAL APPLICATIONS FOR LASERS
Although there are few controlled clinical studies in the literature, documented case studies and empirical evidence indicate that lasers are effective in reducing pain and aiding wound healing.
Low power lasers are best recognized for increasing the rate of wound and ulcer healing by enhancing cellular metabolism.

139. CLINICAL APPLICATIONS FOR LASERS
There have been no ill effects reported from laser treatments for wound healing.
Lasers have also been effective in reducing pain and have been shown to affect peripheral nerve activity.
Chronic pain has been treated with GaAs and HeNe lasers, and positive results have been observed empirically and through clinical research.

140. TECHNIQUES OF APPLICATION
The laser energy is emitted from a handheld remote applicator.
To administer a laser treatment, the tip should be in light contact with the skin and directed perpendicularly to the target tissue while the laser is engaged for the designated time.

141. TECHNIQUES OF APPLICATION
Commonly, a treatment area is divided into a grid of square centimeters, with each square centimeter stimulated for the specified time.
This grid technique is is the most frequently utilized method of application and should be used whenever possible.

142. GRID TECHNIQUE

143. TECHNIQUES OF APPLICATION
Lines and points should not be drawn on the patient’s skin because this may absorb some of the light energy.
If open areas are to be treated, a sterilized clear plastic sheet can be placed over the wound to allow surface contact.
An alternative is a scanning technique in which there is no contact between the laser tip and the skin.

144. TECHNIQUES OF APPLICATION
With this technique, the applicator tip should be held 5 to 10 mm from the wound.
Since the beam divergence occurs, there is a decrease in the amount of energy as the distance from the target increases.

145. LOW POWER LASER

146. TENS