1. Electrical Stimulation
Clinical Application
© 2005 – FA Davis

2. High Volt Pulsed Stimulation
© 2005 – FA Davis

3. Parameters Amplitude: 0 to 500 mA Voltage: 0 to 500V
Current: Monophasic
Amplitude: 0 to 500 mA
Voltage: 0 to 500V
Pulse Frequency: 1 to 120 pps
Pulse Duration: 13 to 100 µsec
Phase Duration: 20 to 45 µsec
Adjustable Parameters
Duty cycle
Electrode alternating rate
Electrode balance
Intensity
Polarity
Probe electrode
Surge/Ramp

4. Theory
Short-duration, high amplitude (voltage) pulses can produce comfortable, moderate contractions.
Short phase duration targets sensory nerves and motor nerves
Wave form is modified to decrease total current to improve comfort
Each electrode has a known polarity
May cause galvanic (ion) changes
Short phase duration and long interpulse interval probably negates any effect

5. Uses Reeducation of peripheral nerves
Delay denervation and disuse atrophy by stimulating muscle contractions
Reduction of post-traumatic edema
Increase in local blood circulation (unsubstantiated)
Restoring range of motion:
Reduction of muscle spasm
Inhibition of spasticity
Reeducation of partially denervated muscle
Facilitation of voluntary motor function

6. Effects Neuromuscular Stimulation Pain Control
Moderate to strong muscle contractions
Less torque production than NMES
Pain Control
Sensory-level (short-term)
Motor-level
Acute pain: Positive electrode over painful site
Chronic pain: Negative electrode over site

7. Effects Edema Control Edema Reduction
Negative electrode may prevent the formation of edema
Causes the gaps between endothelial cells to close, preventing leakage
Edema Reduction
Motor-level stimulation “milks” the venous and lymphatic vessels.

8. Effects Blood Flow Wound Healing
Associated with frequency and intensity of muscle contraction
Wound Healing
Electrode polarity kills or repels different microbes
Assists healing and inhibits bacteria growth
Direct current techniques are more effective than HVPS

9. Notes and Precautions
Motor-level stimulation can cause unwanted tension on the muscle fibers, the tendons, or the bony insertion.
Muscle fatigue can occur if the duty cycle is too high.
Intense or prolonged stimulation may result in muscle spasm and/or muscle soreness.
Improper use can cause electrode burns or irritation.

10. Transcutaneous Electrical Nerve Stimulation
© 2005 – FA Davis

11. Parameters Adjustable Parameters Total current flow 0 to 100 mA
Current: Biphasic
Total current flow 0 to 100 mA
Pulse frequency 1 to 150 pps
Pulse duration 10 to 500 µsec
Phase duration 5 to 250 µsec
Adjustable Parameters
Intensity
Mode (output modulation)
Pulse duration
Pulse frequency

12. Theory
Adjustable phase durations specifically target sensory, motor, and pain fibers
Phase duration is matched with pulse frequency to produce specific effects
Biphasic form prevents net residual charge

13. Uses Control of acute or chronic pain Management of postsurgical pain
Reduction of post-traumatic acute pain

14. Effects High – Frequency TENS (Sensory Level)
Short phase duration (< 100 µsec)
High pulse frequency (60 to 100+ pps)
Sensory-level output
Activates spinal gate
Long-term treatment
Output must be modulated to reduce accommodation

15. Effects Low – Frequency TENS (Motor level)
Long phase duration (150 to 250 µsec)
Low pulse frequency (2 to 4 pps)
Motor-level output
Pituitary gland releases:
ACTH
β-lipotropin
Causes the release of β-endorphin
Binds to the A-beta and C fiber receptor sites
Blocks the transmission of pain

16. Effects Brief – Intense TENS (Noxious level)
Long phase duration (300 to 1,000 µsec)
High pulse frequency (> 100 pps)
Noxious-level output
Very short treatment duration
Creates a negative feedback loop in the CNS
Theoretically “short circuits” the pain carrying loop
Opiates inhibit the release of Substance P
Blocks or reduces pain transmission

17. Notes and Precautions Do not use to treat pain of unknown origin
TENS is a symptomatic treatment
Improper use can result in electrode burns or skin irritation.
Intense or prolonged stimulation may result in muscle spasm and/or muscle soreness.
Intake of 200 mg or more of caffeine may reduce the effectiveness of TENS
Narcotics decrease the effectiveness of TENS

18. Interferrential Stimulation
© 2005 – FA Davis

19. Parameters Current: Alternating Adjustable Parameters Intensity
Beat frequency – Analogous to the number of cycles or pulses per second
Burst duty cycle – Bursts separated by periods of no stimulation (interburst interval)
Interburst interval – Duration of time between bursts
Premodulation (e.g., Russian Stimulation)
Ramp
Sweep – Variation in the beat frequency; Set with a low value and a high value
Vector/Scan – Variation in current intensity
Current: Alternating
Two alternating currents form a single interference current. Premodulated output is based on a single alternating current.
Current: 1 to 100 mA
Current flow (RMS) 0 to 50 mA
Voltage: 0 to 200 V
Carrier Frequency: Fixed at 2500 to 5000 Hz
Beat Frequency: 0 to 299 Hz
Sweep Frequency: 10 to 500 µsec

20. Theory High-frequency waves easily overcome skin resistance
Carrier Wave
Interference Wave =
High-frequency waves easily overcome skin resistance
The two waves are slightly out of frequency
They cancel each other out and produce a frequency of 1 to 299 Hz in the tissues
Results in a comfortable stimulation capable of depolarizing sensory and motor nerves
Variable Wave

21. Uses
Acute pain
Chronic pain
Muscle spasm

22. Effects Pain Control Muscle Contractions Similar to TENS
Most frequently used for motor-level pain control
Muscle Contractions
Neuromuscular re-education
Edema reduction

23. Notes and Precautions
Do not use in the presence of unknown pain or pain of central origin
Can cause electrode burns, skin irritation
Motor-level use can cause muscle spasm or muscle soreness

24. Neuromuscular Electrical Stimulation
© 2005 – FA Davis

25. Parameters Total current: 0 to 200 mA Adjustable Parameters Intensity
Current: Biphasic, Premodulated
Total current: 0 to 200 mA
Pulse frequency: 1 to 200 pps
Phase duration: 20 to 300 µsec
Intrapulse interval: Appx. 100 µsec
Adjustable Parameters
Intensity
Pulses per second
Duty cycle
Reciprocal rate
Ramp

26. Theory Current type varies by manufacturer
Tends to have long phase duration
Biphasic and alternating current decreases possibility of electrode irritation

27. Uses Maintaining range of motion Muscle reeducation
Prevention of joint contractures
Prevention of disuse atrophy
Increasing local blood flow
Decreasing muscle spasm

28. Effects Can produce substantial muscular tension
Capable of increasing strength
Used when limb is immobilized
Also slows the onset of atrophy
Duty cycle is required to prevent fatigue

29. Notes and Precautions
Improper use may result in electrode burns or skin irritation
Intense or prolonged stimulation may result in muscle spasm and/or muscle soreness.
An electrically induced contraction can generate too much tension within the muscle
Use caution:
Musculotendinous lesions, the tension from the contraction may injure the muscle or tendon fibers
Cases where the muscle’s bony attachment is not secure

30. Iontophoresis
© 2005 – FA Davis

31. Parameters Total current: Up to 5 mA Voltage: 80 V
Current: Direct
Total current: Up to 5 mA
Voltage: 80 V
Dosage: 0 to 80 mA/min
Adjustable Parameters:
Dosage:
Amperage
Duration
Polarity

32. Theory
The charges associated with a DC can “drive” medications into the tissue
Medication must have an electrical charge
Negative charges driven from the cathode Attracted towards the anode
And vice-versa
Requires specialized electrodes to hold the medication

33. Dose-Oriented Treatments
Medications are delivered in mA/Min
Milliamp Minutes
Function of the amount of current times the duration of the treatment:
5 mA applied for 20 minutes
5mA * 20 min = 100 mA/Min
4 mA applied for 25 minutes
4mA * 25 minutes = 100 mA/Min
Dose-oriented treatments provide the basis for the Ionotopatch™ which delivers the medication using a low current applied for an extended time.

34. Uses Delivers medication to the tissues to treat: Acute inflammation
Chronic inflammation
Arthritis
Myositis ossificans
Myofascial pain syndromes
Delivering local anesthetics before injection or other minor invasive procedures
Hyperhidrosis

35. Sample Medications Medication Pathology Concentration Dosage Polarity
Acetic acid Myositis ossificans 2% 80 mA/Min Negative
Dexamethason Inflammation 4mg Decadron 41 mA/Min Negative and lidocaine Pain control 4% Xylocaine 40 mA/Min Positive
Lidocaine and Pain control 4% Lidocaine 30 mA/Min Positive epinephrine mL/1:50, mA/Min Positive
Dexamethasone Inflammation 2cc 4mg/mL 41 mA/Min Negative
Refer to the prescription for the exact treatment parameters.
Each electrode size has a maximum treatment amperage. Consult the packaging information included with the electrodes.

36. Notes and Precautions
Controlled medications require a physician’s prescription:
Each patient requires his/her own prescription
Follow any notes or instructions provided by the pharmacist.
State practice acts may further regulate the delivery of iontophoresis.
The exact medication dosage delivered is unknown.
Erythema under the electrodes is common
Too intense of a treatment dose can result in electrode burns
Do not reuse electrodes
Medications remain, contaminating the electrode

37. Microcurrent
© 2005 – FA Davis

38. Parameters
Current: Monophasic. (Polarity reverses)
Total current flow: 1 to 999 µA (Peak current) 25 to 600 µA (RMS)
Pulse frequency: 0.1 to 1000 Hz
Pulse duration: 0.5 to 5000 µsec
Phase duration: 0.5 to 5000 µsec
Adjustable Parameters:
Intensity
Polarity/alternating polarity
Ramp
Threshold – Ohm Meter

39. Theory
Small, subsensory pulses can affect the function of healing tissues
Injured tissues have a reversal of their normal electrical charges (“injury potential”)
MET attempts to normalize the electrical potential
Activation of ATP and increased ATP levels
The efficacy of MET has not been substantiated.

40. Uses* Acute and chronic pain Acute and chronic inflammation
Reduction of edema
Sprains
Strains
Contusions
Temporomandibular joint dysfunction
Carpal tunnel syndrome
Superficial wound healing
Scar tissue
Neuropathies
* Efficacy has not been established

41. Notes and Precautions
If the patient is dehydrated, nausea, dizziness, and/or headaches may result.
Electrical “shocks” may be reported by the patient when MET is applied to scar tissue.
Caused by decreased electrical resistance.