Electrotherapy

Electrotherapy Overview

• Electrotherapy involves different techniques described elsewhere.
• It affects the body through nerve stimulation, muscle contraction, pain modulation, tissue healing, edema control, and iontophoresis.
• Nerve stimulation activates sensory or motor nerves via frequency and intensity.
• Muscle contraction achieved via NMES or FES promotes strength and function.
• Pain modulation using TENS and IFC impacts nociceptive pathways, involving gate control theory and endogenous opioid release.
• Tissue healing sees HVPC and LIDC influencing cell migration, circulation, and inflammation.
• Edema control alters vascular permeability and muscle pumping through electrical stimulation.
• Iontophoresis moves ions or medications across the skin.

High-Voltage Pulsed Current (HVPC)

• HVPC is used for galvanotaxis, activating cells via membrane alteration, and enhancing antimicrobial activity
• It improves circulation and reduces edema from inactivity
• HVPC supports wound healing
• Indicated for edema (4-7 days post-injury), inflammation, lack of muscle control, and open wounds

Contraindications and Precautions for HVPC

• Do not use with demand-inhibited pacemakers, unstable arrhythmias, or local malignant tumors
• Do not apply HVPC to areas with malignancy.
• Avoid in the region of the carotid sinus, pharyngeal, or laryngeal muscles
• Avoid with venous or arterial thrombosis or thrombophlebitis
• Avoid in the pelvis, abdomen, trunk, and lower back during pregnancy
• Avoid over superficial metal implants or areas treated with metal ion topical agents
• Avoid with active bleeding or open wounds and osteomyelitis or thrombophlebitis
• Questions to ask the patient:
  • Does the patient have a pacemaker or heart conditions?
  • Does the patient have a history of cancer or cancerous tumors?
  • Are they pregnant or think they might be?
  • Do they have any implants or stimulators?
  • Have they recently used topical agents containing metal?
  • Inspect the area for deep wounds, cuts and abrasions
  • Is there any infammation or infection near the bone?
  • Do they have any blood clots in the area?
  • Do they have any heart conditions?
  • Is there impaired sensation/mentation?
  • Assess for skin eschar, heavy scarring, or thick adipose tissue.

HVPC Setup and Parameters

• Position the patient comfortably throughout the treatment
• Elevate the treatment area if using HVPC for edema reduction
• Place electrodes over target muscles and set appropriate parameters
• Ensure patient can reach the clinician if needed
• Assess treatment outcomes
• Tissue healing-inflammatory phase: 60-125 pps, Preset 40-100µs, comfort tingling, negative, 45-60 minutes
• Tissue healing-proliferation phase: 60-125 pps, Preset 40-100µs, comfort tingling, positive, 45-60 minutes
• Edema control: 120 pps, Preset 40-100µs, comfort tingling, negative treating electrode (+) towards core, 30 minutes

Interferential Current Purpose

• Interferential current is a treatment for pain control, and can reduce analgesic medication intake.
• Conditions it can help to manage:
  • Osteoarthritis
  • Rheumatoid arthritis
  • Patellofemoral pain syndrome
• It can deliver current to deeper muscles than TENS and can be used for muscle contraction as well.
• Can be used for deep, aching, chronic or superficial acute pain.

Interferential Current Indications

• Acute pain
• Post-operative pain
• Chronic pain
• Osteoarthritis
• Rheumatoid arthritis
• Patellofemoral pain syndrome

Interferential Current Contraindications and Precautions

• Do not use with demand-inhibited pacemakers or unstable arrhythmias, or local malignant tumors
• Do not apply IFC to area with malignancy
• Avoid in the region of the carotid sinus, pharyngeal, or laryngeal muscles
• Avoid with venous or arterial thrombosis or thrombophlebitis
• Avoid in the pelvis, abdomen, trunk, and lower back during pregnancy
• Be cautious if there is active bleeding or open wounds , osteomyelitis, or transthoracic stimulation
• Ensure you ask the patient about:
  • Existing pacemakers, heart conditions, any allergies of existing conditions
  • History of cancer, or if they have malignant tumors
  • Pregnancy or possible pregnancy
  • Any heart defects
  • Impaired mentation
  • Superficial metal implants
  • Corticosteroid use

Interferential Current Setup

• Assess the patients sensation of the area to be treated
• Position the patient comfortably for the duration of the treatment
• Remove metal and clothing in the treatment area and inspect the skin
• For larger treatment areas a quadripolar electrode set-up is commonly used
• Place the electrodes to bracket the target treatment area
• Connect the first set of lead wires in a diagonal
• Connect the second set of lead wires to the remaining electrodes in the opposite diagonal
• Select treatment parameters
• Turn on machine
• Provide a way for the patient to reach the clinician during treatment as needed
• Assess outcomes after treatment

Interferential Current - Bipolar setup

• Assess the patients sensation of the area to be treated
• Position the patient comfortably for the duration of the treatment
• Remove metal and clothing in the treatment area and inspect the skin
• For smaller treatment areas a bipolar electrode set-up is commonly used
• Place the electrodes to bracket the target treatment area
• Connect the leads to the electrodes
• Select treatment parameters (Pre-modulated or Pre-mod)
• Turn on machine
• Provide a way for the patient to reach the clinician during treatment as needed
• Assess outcome

Interferential Current - Parameters

• Acute pain: 100-150 Hz, throughout duration of the treatment, use if available, to produce tingling, 100-150 Hz
• Chronic pain: 2-10 Hz, 20-30 minutes, none, to visible contraction, 2-10 Hz

Iontophoresis Purpose

• Iontophoresis directly delivers medication to a local site while bypassing the liver.

Iontophoresis Indications

• Point specific pain
• Inflammation
• Lateral epicondylitis
• Infrapatellar tendonitis
• Tendonitis at the shoulder
• Rheumatoid arthritis
• Plantar fasciitis
• Achilles tendon pain

Iontophoresis Contraindications and Precautions

• Consider intended medication contraindications and anesthetized skin areas
• Questions to ask the patient:
  • Ensure you're aware of the contraindications of the intended medication
  • If their is impaired sensation of the skin
  • If they have recently applied a topical analgesic
  • Does the patient have a pacemaker or heart conditions?
  • Do they have implanted stimulators (phrenic nerve or bladder)?
  • Over the carotid sinus
  • Does the patient have a blood clot or is prone to blood clots?
  • Is the patient pregnant or possibly pregnant?
  • Does the patient have a history of cancer or cancerous tumors?
  • Asses the skin or eschar or scarring in the area
  • Assess for extreme odema
  • Are they allergic to the medication being prescribed?
  • Do they have discomfort or burning from excessive current density?
  • Is there any impaired mentation?

Iontophoresis - Setup

• Assess the sensation of the area to be treated
• Place the patient in a position that is comfortable for the length of the treatment
• Make sure that the skin is clean
• The dispersive electrode should be placed at the site proximal or distal to the active electrode
• Space between the electrodes should be at least the size of the active electrode
• Pick the electrode type based on the desired shape and size needed
• The polarity of the drug delivery electrode should match the polarity of the medication
• The negative electrode should have dexamethasone applied to it
• Place the drug delivery electrode over the target treatment tissue
• Slowly increase the amplitude while checking patient comfort and tolerance
• Set the amplitude to a comfortable intensity - up to 4mA
• The typical suggested dose is 40mA-min
• Check in on the patient throughout the treatment session and adjust the intensity as needed
• Provide a way for the patient to reach the clinician during treatment as needed
• Check the skin after the treatment while carefully removing the electrodes
• Assess the outcomes after the treatment
• Higher intensities, increase rate of medication delivery, but may reduce the drug retention in the area. Lower intensities over longer periods of time, may be more tolerable and may increase the drug retention in the target region.
• Medications require a prescription.

Iontophoresis - Parameters

• Current amplitude of 1mA applied for 40 minutes, with a dose of 40mA-min
• Current amplitude of 2mA applied for 20 minutes, with a dose of 40mA-min
• Current amplitude of 3mA applied for 13.3 minutes, with a dose of 40mA-min
• Current amplitude of 4mA applied for 10 minutes, with a dose of 40mA-min

TENS Purpose

• TENS activates a pain gate by activating non-nociceptor A-beta nerves to inhibit nociceptive signals at the spinal cord level.
• It can reduce analgesics for pain.

TENS Indications

• Acute pain
• Post-operative pain
• Chronic pain
• Nonsurgical management of knee conditions

TENS Contraindications and Precautions

• Do not use with pacemakers or defibrillators
• Avoid over the carotid sinus, laryngeal/pharyngeal muscles, sensitive eye areas, or mucosal membranes
• Do not use with venous or arterial thrombosis or thrombophlebitis
• Ask the patient:
  • Do you have a pacemaker or defibrillator?
  • Check for a history of cancer, or malignant tumors
  • Are women pregnant or planning to be pregnant?
  • Do you have any heart defects?
  • Impaired mentation
  • Skin irritation
  • Whether there are any children at home
• Limit intense mode to 15 minutes at a time, for low rate tens

TENS - Setup

• Always assess the sensation of the area that will be treated, prior to beginning treatment.
• Place the patient in a comfortable position for the duration of the treatment
• Place the electrodes to bracket the area of the pain
• Connect the electrodes to the leads to administer the wavelength you desire based on your target teartment, and according to the machine
• Slowly increase the intensity to achieve the desired effect
• Provide a way for the patient to reach the clinician during the treatment if needed
• Assess outcomes after treatment

TENS - Parameters

• Conventional high-rate/sensory TENS: 100-150 pps; pulse duration is 50-80µs; amplitude is sensory; only while the pain is present
• Low-rate/motor TENS: 100-150 pps; pulse duration is 200-300µs; amplitude is small muscle contraction; maximum 20-30 minutes every 2 hours; 4-5 hours following the treatment. -High freq is 100-150 Hz and 50-80 pulse duration, sensory
• Low rate is <10 Hz, 200-300 pulse duration, m contraction

Neuromuscular Electrical Stimulation (NMES)

• NMES Electrical stimulation is used for weakened individual muscles and patients who cannot contract actively
• This strengthens and improves the recruitment of muscles
• Can decrease spasticity
• Improves range of motion and endurance, by decreasing edema
• Aids in reducing or preventing shoulder subluxation

NMES - Indications

• NMES can be used to assist patients with muscle spasm
• Impaired range of motion
• Muscle re-education
• Disuse atrophy
• Edema reduction
• Spasticity
• Denervated muscle

NMES - Contraindications

• Do not treat patients with cardiac pacemakers
• Do not treat the area when active motion is contraindicated
• Malignant tumors
• Over the carotid sinus
• Active bleeding in the area
• Venous or arterial thrombosis or thrombophlebitis
• Application of electrodes over pelvis, abdomen, trunk, and low back during pregnancy
• Disoriented patient
• Metal implants in area

NMES - Precautions

• Always assess the patients sensation of the area to be treated
• Cardiac disease
• Chronic corticosteroid use
• Impaired mentation or sensation
• Skin irritation or open wounds
• Extreme edema
• Ensure the patient is comfortable
• Select the electrode size depending on the NMEStreatment
• Apply one electrode over the muscle belly
• Apply second electrode over the muscle to stimulated parallel to the muscle fiber direction at least 2inches away from the first electrode
• Select treatment parameters
• Gradudally increase the intensity
• Instruct patient though functional exercise as indicated
• Assess for any cuts or active bleeding, as well as observing the skin and alertness of the patient
• Question for any metal implants, heart conditions, corticosteroids, and pregnancy

NMES Parameters

• Frequency: 35-80 pps for strength and 35-50pps for re-eduction
• Pulse Duartion-Amplitude:
  • To >10% or MVIC in injured >50%
  • MVIC in uninjured
• On: off time
  • 6 to 10 seconds on, 50 to 120 seconds off (Ratio is about 1:5 Initially)
• Ramp time
  • At least 2 seconds
• Treatment time
  • 10-20 minutes to produce 10-20 repetitions
• Times Per Day
  • Every 2 to 3 hours while awake
• Muscle Spasm Reduction On off = 2 to 5 seconds (Until Sapsm has relieved) and edema using muscle pumps on/off = 2 to 5 as well (twice a day for this )

Key Clinical Parameters

• Pulse Duration determines which nerves/muscles are recruited
  • Short pulse duration (<150µs) activates sensory nerves, good for pain relief (TENS)
  • Long pulse duration (>200µs) activates motor nerves, used for muscle strengthening (NMES)
• Frequency:
  • Low (1–10 Hz) activates endogenous opioid pathways
  • Medium (30–50 Hz) produces smooth tetanic muscle contractions
  • High (80–150 Hz) affects sensory nerves (pain relief)
• Amplitude is adjusted for patient comfort and treatment goals

Choosing Electrotherapy

• Acute pain managed with conventional TENS with high frequency and low intensity.
• Chronic pain requires low-rate TENS with low frequency and high intensity.
• Deep pain benefits from IFC due to its penetration capabilities.
• Weakness after surgery or injury: NMES helps with muscle re-education,
  • Russian current using 2500 Hz, 10 msec bursts, 10-second contraction time and 50-second off-time for 10 repetitions.
  • Aussie current using 1000 Hz, 4 msec bursts.
• FES is beneficial for Neurological conditions (e.g., stroke, SCI) (functional movement training).
• Wound Healing and Edema Control indications:
  • Acute wounds: HVPC
  • Chronic wounds (pressure ulcers, diabetic ulcers): HVPC or LIDC
  • Acute edema: HVPC with cathode over swelling
• Administering Medication achieved via: Iontophoresis

Clinical uses by modality

• TENS: Primary use is pain modulation, via gate control theory, and the release of endogenous opioids, parameters: Conventional (High Freq:80-100 Hz, sensory), Low-Rate (1-10 Hz, contract)
• NMES: Primary use is Muscle Re-education, Strengthening, involves Direct stimulation of motor nerves, parameters: Frequency: 35-50/80 Hz, Ratio: 1:5, 150-350 pulse duration, contract, ramps
• FES Functional Electrical Stimulation: Helps with Movement Assistance, Stimulates functional muscle activation, Customized timing based on activity, similar to NMES for m activation
• HVPC: is for wound healing, and edema control, involves Cell migration, Capillary permeability, parameters: Monophasic, High-Voltage, Pulsed, High Freq, Sensory
• IFC: is useful for Deep Pain Relief, Acute/Chronic, operates via Beat frequency modulation, , parameters: Quadpolar – Larger Area, Bipolar – Smaller Area; High Freq acute pain; Low Freq – chronic pain
• LIDC: Indicated for Chronic Wound Healing, Galvanotaxis (cell migration), Low voltage, long duration