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no killing your patient. Edema caused by that can be the source of the arterial insufficiency or the venous stasis ulcer, but if in reducing that edema, you're going to overload the cardiac system. Not really worth it, right? It's better to have a wound and be alive, so you have to weigh those odds...

no killing your patient. Edema caused by that can be the source of the arterial insufficiency or the venous stasis ulcer, but if in reducing that edema, you're going to overload the cardiac system. Not really worth it, right? It's better to have a wound and be alive, so you have to weigh those odds. Parameters, you talked about this, electrodes to talk about this. There you go, at and far away. Filtration, we talked about it. Polarity, we talked about it. Frequency, done, done. Treatment time, oh my God, we're done, get out. Actually, we had our advisory committee meeting last night where I talked to the members of our advisory committee, our PTs and PTAs from our region, from all different settings, from acute care to skilled to outpatient, to more of an administrative, and home health. So, of course, we have a pretty wide variety. And I asked them, I said, what modalities are you using? Or do you see use, whether it's by you or... I was kind of down towards the bottom. That said, these are easy test questions for the boards, right, because they're black and white. It is do this, for this, this setting, for this. It's very cut and dry, so there is quite a bit that can come up on the boards in any one of these things, which is why I hate teaching for a test because really I should be teaching you for your career. But, in the grand scheme of things, I also have to get you to that career. In other regions of the country, they do use different things. If you go south, like to the southeast corner of the country, they do, PTs and PTAs do more wound care there than just about the rest of the country. And so with that, you'll see some DC current to have that aspect of it for the wound care specifically. Functional electrical stimulation, we're gonna chat about it, but it's why I took it off of your sheet for the jigsaw classroom because it's a type of DC current, but it's a wearable device, and I have some videos that, if you guys have watched the videos, you may have seen them. But they're wearable devices that are set up by the companies, and they teach them how to do it, but it's for people that have, say, foot drop and they have no dorsiflexion for whatever the reason may be, or MS, where they have little to no activation of their ankles, so they can have these wearable devices that when triggered by a weight shift or by stimulation in another muscle, will kick on that specified muscle to contract, to allow them to walk or to pick up their foot without tripping, stuff like that. So FES, functional electrical stim, is really, I mean, we need to know about it, but in reality, we're not generally the ones applying it because it's coming from the company that is making it and supplying it and giving it. TENS, which is what Ashley had in hers, Transcutaneous Electrical Stimulation, that is so cheap now that it's really, you need to understand two different settings of it, whether we're gonna do the acupuncture setting or we're going to do the gait theory setting, and there are two different sides, and then how to set that up and how to teach your patient to use it because it's at home use. We're not using them in the clinic. Back when I started, TENS units would run between $300 and $500. So patients would rent them on a rent to own and if they used them long enough, then they became theirs, right? Now you can get them at Walgreens for between $30 and $50, so you can have them delivered to you on Amazon. There are, you can just push the button for the region you want. Those are not my favorite because I don't know what that region is set at and you can't modify those preset things, like if I pick a neck, it just, what is it? I don't know, you can't change it, right? So I'm a huge fan of the old school analog ones because I can change those dials and get the settings, that's what we have, get the settings to exactly what I want and teach my patient how to change it so that when they get used to it, they know how to modify it, right? But that's really all we're doing nowadays is teaching somebody else how to use this device. We're not using it clinically. But we are absolutely using IFC and Russian to... Electrons that are flowing from one place to another So when we most of our stuff that we're using is electrons, but we can have ions That's how you can make a battery out of a lemon Have you guys seen those right and you make a battery out of 11 that's using ions that electrons, right? So it can be either one But it's a charge right because an electron is a negative charge and an ion can be a negative or positive But it's movement of those charged particles from one place to another If I'm moving an ion I'm going to move it from plus to minus or from minus to plus It always is going to their offices because opposites are going to attract So the use of electrical currents for pain management and the gate control theory was used all of that in But it was used Way before that They used to take Electric eels Right the little snakes of the ocean Those little guys they would grind them up and use them as a poultice like rub it on person Because it would still have an electrical charge That's how they used electrical stimulation before we had electricity right they would grind up electric eels and Sameer Samania But they've been using this for various types of electrical current for pain management for a long time, but Mackenzie and Malice, Matt and Melzack and walls are the ones that Really created Electrical stimulation like we have today in the theory of pain management in about the 1960s So today we use it as I mentioned for muscle contraction if we're going to be using like pulse by phasic or Russian for that Controlling all different types of pain whether it's a cute chronic post-operative And then promoting tissue healing that's gonna be like a wound care and our DC current Okay, so let's talk about DC and AC DC it's not a band this band my son's favorite band I don't know how an awful 11 year old decided easy DC Yeah Black is the best album ever I hear this all the time and I go Who I don't think I could pick that out of the head to Direct current DC that's a fact Okay, so when you have a battery I had a battery It was on basic for the win on a battery you have a plus and a minus sign Right. It's always gonna be plus and it's always gonna be minus whether it's on one end and the other end or on a nine Bolt, you know plus and minus because it's always flowing in one direction It's direct from plus to minus it never changes Okay, that's direct current That was Edison Edison did direct current Nikola Tesla Did a C current not Tesla as an Elon Musk? He just stole the name He just found a cool name from a pool guy that did some cool things He said yeah, I want to use that right he has zero to do with it. So Nikola Tesla was actually Edison's What do you want to call it Apprentices like, you know, he oh no, it was never a psychic. I think I never had a lot of that Apprentices and the problem though is Tesla may have been a little bit smarter than Edison Edison did not care for it big differences Edison came from money Tesla came from poor immigrants. So who do you think won that battle? I mean we had Edison companies and Edison light bulbs, but we do not have Tesla light bulbs Edison won You know money wins unfortunately, but but Tesla really drove the AC current and AC current is all of our plugs So think of everything that gets plugged in right and the AC current means it alternates It goes this side is plus and this side is minus and then it switches and this is plus to minus and then plus To minus plus to minus plus minus plus times so it switches back and forth Constantly on a very specific pattern. So when you see frequency or Hertz That right there tells you it has to be a C because it's alternating from plus to minus in that little sine wave I had before or in the sine wave that you see here Right. So in this sheet that up and down up and down That's your alternating current going from plus to minus plus to minus Where DC would just literally be aligned straight across Until the battery fails and then it's slowly going to go down to the neck to the zero right Say I'm sorry Yeah Hurts anything like that anything with Hertz H HZ that stands for Hertz And a pulse current is anything that goes on and off on and off on and off on and off It can go on and off very rapidly. It can go on and off very slowly But anything that's on and then off and that can be AC or DC But most of the time we see that with AC currents So again back to our little sheet here We have a frequency at the top of AC that's just going straight across That's just a frequency of AC but then right below it you see it's the same frequency But then there's a pause and then it goes again and a pause. That's your pulse current right Pulses in there So just a little bit more Continues direct current continuous unidirectional flow of charged particles So we use direct current when we need to have a charge created within a region If we need to have so it says on their ion to for recess, right? We kind of mentioned that on Tuesday, that's where we push a medication that is Polarized it has a charge into the skin Obviously, I don't want it to go plus minus plus minus plus minus because if my medication has a positive charge to it Then it's going to repel attract repel attract repel attract. It's literally not going to go anywhere And I wanted to move into the tissues We also use it for de-innervated muscle So yes, we use Russian and we know Russian muscle contraction we all saw that here some of you found it pretty great with the the post-biphasic Right the two types of ISC where you just use two pulse by phasic Because Russian is a type of pulse by phasic, but you can get a muscle contraction that way But when we are using an AC current, we're stimulating the nerve To release acetylcholine to contract the muscle Right. So we are stimulating the nerve Which is why some of you when you had it as like no you have to move it over a little bit because you're not going To be on that muscle belly We need to be over where that if you can get it directly where that nerve innervates the muscle or that nerve comes into the muscle That's going to be your best contraction Right because we're stimulating the nerve It's how we can put things up on the neck and stimulate down lower because we're getting the nerve Not necessarily Contracting the muscle itself, but DC current will contract the muscle itself because it will depolarize the actual muscle or that sarcoplasmic reticulum to release the calcium Hang with me here right to release the calcium That goes on to the troponin and tropomyosin to open up the actin binding sites to allow the cross bridge Right. We remember all of that. So its job DC current is Releasing that calcium from the sarcoplasmic reticulum does not need the nerve at all So that's why in our functional electrical stimulation the wearable devices We're gonna use DC because the nerve is not working because the nerve is Demyelinated like an MS or we had a spinal cord injury or something has happened to the nerve So it's not working, but I want the muscles to work Problem with that extreme fatigue quickly You can't force a muscle to contract and not have any recovery time and Expect it to last a long time it fatigue very very fast When we are stimulating I might be jumping ahead a little bit, but it's okay when we are stimulating those de-innervated muscles I'm like when we do it ourselves We don't get that one third of the muscle Contract you remember back and I think it was in kinese when we talked about it that we always get about one third of the maximum contraction at a time Because you kick on this third and then it fatigues and you kick on this third and then it fatigues and you kick on this Third and by the time that fatigue the first one can is ready to go again And then the second one and then the third one and it keeps doing this right to prevent our muscle fatigue We don't get that in DC. We get all three at once and all three gone All three at once and all three gone. There is no time for recovery So that's why we fatigue quickly with DC That's also really great if I'm trying to fatigue something If I'm trying to wipe out something it's a great way to do it. Hmm You can't really use it for clonus, right? But we can use it for spasms and things where I'm trying to wipe it out There is a way and we'll see it here in a little bit that you can do a nerve block Using DC current because you're literally flooding the nerve With the ions that are gonna hyper polarize it making it too hard To get that deep polarization so that we can't feel pain can't have that nerve sensation. They've used it on on Dental work So they'll put a DC current on for 15 20 minutes and it wipes out the nerves because we can get to this facial and Trigeminal nerves real easy right there right there so we can wipe those out They can't feel any sensation They keep it running do the dental work turn it off and within a few seconds The nerve has re-polarized and all of your sensation is back with no carryover Kind of freaking cool when you think about that problem is is that it doesn't work perfectly on everybody where it's like no became does almost ish But so that's DC current right one flow of particles from plus to minus never changing AC current Alternating current going from plus to minus bi-directional flow still moving particles, but now those particles are Alternating they're kind of going back and forth like a wave pattern So we use this for pain Because we can stimulate those sensory nerves to feel it We're not stimulating them the same way as DC current in way of it amount We're just literally it's like like if you're touching up right you're just doing a really intense touch on those sensory nerves It's flooding the brain with all of that input and I can't feel the slow pain because no susceptors notoriously slow right So those pain nerves are slow, but the nerves that are going to feel the electrical stimulation are much much faster So we use it for pain control in the gate theory We can also use it for pain control in the acupuncture theory like intense we have those two different types with gait and acupuncture because we can create pain and You know when you have a headache and people tell you like to pinch your ear your web here really really hard And it hurts really really bad, but then your headache starts to go away Never done that Or if you're my mom and you have a headache she does come here. I'll stomp on your foot your head won't hurt so bad Does your mom ever say that to you? Just my mom just the love just a lot that we got The reason that works though is endorphin It hurts our body releases endorphins endorphins decreases pain, right? So we're literally flooding our body with endorphins that are gonna decrease the sensation of pain so we can do that through Uncomfortable tense application we can make it hurt It usually hurts in a different way if you have a joint or You know your joint surgery or you have chronic Let's say osteoarthritis right what's never gonna get better it is what it is You're just trying to save it off as long as you can you know what's gonna hurt well I can eliminate that pain for a little while flood the body with endorphins so it doesn't feel the pain The cool thing about it is that usually lasts a few hours after we turn it off because those endorphins are still flowing Right, so not only can I get through my therapy session? We can work on strengthening and range of motion, but then it's gonna last a little bit longer, too So that's how we use it for pain management with AC current And then of course we can use it for muscle contraction of Innovated muscles that has to be the key there. We do not use AC current for de-innervated muscles only innervated again, but Nikola Tesla This is like I said, we put something in in the United States. We use 60 hertz Also the electricity is 60 hertz This is why you cannot plug your flat iron in to an outlet in Europe They don't use the same hurts It's why the plugs look different right you have to get adapters so that you don't blow up the whole thing So 60 Hertz means that it is going plus to minus 60 times in one second So when you see that word hurts HZ, it's how many times in a second are we alternating from plus to minus? So 120 Hertz 120 times a second So on our sheet here I Did 25 Hertz Okay, so it alternates 25 times in that one second So Imagine 60 Hertz how many would have to be crammed in here to get to 60? It's pretty quick, right? They get to be really short and then It continues on our pulse down here. It's still the same hurt Still would move 20 times in a second, but this time it's pulsed So it's got one two three four five six pulses if this was reading upside down Pulse per second. Oh, sorry. This was two seconds here two seconds. I doesn't make any sense So this is one second. So you have three pulses in that one second at 25 Hertz Does that make sense How this how this works so your pulse per second abbreviated PPS pulse per second Does not have to do with the frequency of the alternating currents It's how many on-offs are happening in that second? So you're gonna have a pulse per second and a An alternating current per second that frequency That are different they're both per second, but they are different Kind of making a little sense clear ish Any questions on that so our household electricity does not pulse right it's it's solid 60 Hertz a second Continues we have a nice stable electrical grid so that 60 stays pretty stable The intensity of that is gonna change depending on How much is going through that wire if you have a 110 outlet? Then it's 110 at your intensity. It's gonna be your amplitude Okay 110 amps Where your dryer is usually a 220? Because it gets a higher amplitude The Hertz is still a hundred or still 60 that doesn't change how big it gets in that 60 seconds. That's your amplitude That's how big your wave is and Making sense so far Questions on that This is kind of the foundation that we're gonna keep talking about that's why I want to make sure that this makes sense The 25 is that's making it it's an AC current yes It doesn't include the pause because it goes on pause on pause on pause in three seconds one second That's my cycle. It's like a fly to that It is in that though. Can you see how they're the same? Yep, so literally if you were to take this I copied this and I moved it down here So these are exactly the same I just added a little pause on it and the pause can be the same As this or it can be longer can be stronger a clean that can change Oh Who's right there Get in there during lecture Fantastic Yes, and we will get to it because they have a couple different ways I Think it's gonna drop something on the board Okay, so here's just a picture of direct current and AC current direct her it does not matter if it's plus or minus All right, it's always just gonna be one or the other so my little my kids went to a science camp and They made these little robot car things And all you have to do is take the battery out and flip it the other direction and put it in and it goes the opposite Way because it doesn't matter. It's running on a DC current. So if the plus is here, it's gonna go forward But if the plus is here, it's gonna go backwards. So for that device, it doesn't matter what direction it works Most of our devices that we use though have a one directional flow That's why you have to line up the pluses here the minus is there when you think about it Where AC it's gonna constantly change Oh my little gift never works here It was a cute little But there's AC versus DC current Mmm, so watch the little electrons moving DC is always moving from the top clockwise to the bottom AC though is switching and it goes right Left or clockwise counterclockwise clockwise counterclockwise, right? So those would be your ions or your electrons your particles alternating back and forth Clear as mud so our pulse current is It's going to be where we take that AC or that DC can be either one and we pause it for a second So just where we interrupt the flow of charged particles So it's on and then it's off and then it's on and then it's off So there is a point when no current is flowing through We use pulse For a lot of our stimulation That especially for pain control No, I'm sorry, especially for muscle contraction Because it stimulates the nerve a little bit more Normally our brain does not send down constant currents to those nerves and this is Kind of mimicking that right we're sending a current not sending a current sending a current not sending a current But when we are thinking about a pulse current This is not generally something that is Is able to be felt Right because this is vibrating and it's almost just that vibration you're feeling in that tingle All right. So when you had Russian on because I think most of you felt Russian on Tuesday If not, you will all the time That had that's a pulse current But you couldn't feel that because it's pulsing during the on not during the off not during your brain Right during that five or ten seconds that your muscle was contracting. There was a pulse in there So it's usually sub threshold of our sensation But our nerves feel it right and it helps them to prevent fatigue and wiping out those nerves But I don't want pulse if I'm trying to do something like IFC or I'm trying to just keep that pain Eliminated Or if I'm trying to induce muscle fatigue I want to minimize that pulse or that rest break at any point that I can because I'm trying to wipe out that nerve or decrease that muscle spasm But honestly for most of our electrical stimulation outside of IFC We use a pulsed current even our one that mimics IFC pulsed by phasic It's in its name right pulsed by phasic. We're using that pulse in there So here's your pulse by phasic on here. Same thing is what's on your sheet You have the same Frequency that same hurts doesn't change but on this one we have an even pulse of ten seconds ten milliseconds on ten milliseconds off And so it's just that off. It's in milliseconds if it was in seconds Then that would be a duty cycle Right, that would be something that you could sense you could feel that if it was one second on one second off But it can be doing this on off on off For a second and then a complete rest break for another second How are we feeling on pulse? Timmy was like you're working on a question. I'm just Just doing putting it towards what we're doing on Tuesday. Because the pulse sounds like what we were doing when we were doing the duty cycle It's of the duty cycle is the bottom of this sheet I'm just gonna keep using your sheets Okay Thought you could fill out the the other sheet already and I was like holy buckets and I realized it was So here if I were to take this and Shrink all of this over here Right. This is this block right here It's this is it's on its pulse during that time frame during this on time frame But then I have a equally large off Where nothing is happening. That's the duty cycle. So I have a frequency I Have a pulse rate and I have a duty cycle all Including each other Right. So this down here is still a frequency of 25 Hertz. It's still three pulse per second But now I have a duty cycle of one two seconds on one So a duty cycle of one to one or two seconds two seconds So all three things would be noted in your documentation 25 Hertz so 25 HZ three PPF three pulse per second two seconds slash two second duty cycle question Okay Okay, that's perfect It's all the same frequency all the way down I Did that on purpose? It actually took me a really long time to get those sideways perfect Because I had to make one And copy and paste it over and line it up perfectly and then copy that and move it over copy that and move it It was painted my ass Okay Some characteristics of electricity So we're gonna go through each one of these we're gonna go through the charge voltage conductors insulators current watts frequencies and resistance whoo The beauty is some of these are gonna flow into our ultrasound as well because things like resistance and conductors and insulators Those are all in us right and those are gonna carry over into ultrasound as well or diaspora Any of our DP because it doesn't matter if I have an insulator that is a rubber Around a cord or if I have fat they're both insulators They both do exactly the same thing one just happens to be biologic and what happens to be mechanical Right, but it's exactly the same thing. So the terms mean the same whether I'm talking sound or electricity Okay, so I gave you a lot on here because I really think your book Doesn't give you enough So this is me supplementing your literature. Okay, so I know there's a lot of words on here But this is in addition to your text Why I did it this way So a charge is going to be when we're talking our electrical stimulation it's going to be electrons And it's going to be a gain or a loss of electrons So if you gain an electron, it's going to be negative because electron is a negatively charged particle and if you lose an electron then you're gonna have a positive charge Because you're gonna be short one Do we remember this kind of from the chemistry side of our anatomy and physiology You guys have to remember my degrees in chemistry so to me this makes total sense, but I need to make sure it makes sense to you Yeah, well if you're balancing equations you have to make sure that everything on the left side is on the right side Right all of your ions all of your chemicals are carried over. Yeah Right so but if I steal one from you like sodium And chlorine to make sodium chloride your table salt right sodium donates an electron to chlorine So then it becomes chloride Right and then that's how we get table salt and a CL and a plus CL No H2o is not an ion so you have to think about an ion bond ionic bond is this do you remember that? I'm sorry. You're welcome. Ah Okay, I just had my brother do all my homework for chemistry All right tonight do you guys have grapes at your house you brought great Let's go we're gonna go downstairs On break we're gonna steal one of her grapes Make a battery in the microwave So, okay you can you can do this I don't want to get fired. So I'm not gonna do it. We definitely do it the collab though. So Where I have to use microwave take a grape you can do something with potato, huh? You can do the a scraper potato they both work beautifully because they're both full of ions Right you slice it So that you don't cut all the way through the skin. That's the key. We need that skin to be our connection And then what happens is as we microwave it Ions flow from one side to the other And they spark as they cross that little bridge of skin Till the skin fries up and then there's no more connection and it stops Potatoes are much bigger So it's a little bit more dangerous with a potato plus it's harder to keep the skin intact when you're cutting a potato and trying To lay it open pretty super easy um But it's just flow of electrons. That's all it is movement of ions or electrons So I put in here recall from amp That a cell depolarizes to initiate or transmit a signal to another cell by the movement of ions the ionic flow So the movement of ions across a membrane. So we had Our resting membrane potential of a nerve Remember this you have to meet the threshold and as soon as you meet that threshold it opens up The sodium channels and the potassium channels the sodium potassium pump To flood and all these ions are going to move in or out of the cell depending on which ones we're talking about And they're going to change the charge Of the cell and in doing so stimulates the next group in the next group and then it's like dominoes, right? You move you you you push one domino over and it's going to hit the next domino the next one the next one So you open these sodium pumps you open these these these these these And the reason it only goes one direction is because we have depolarized over here It can't go that way because it's already open and depolarized So now it's going to have the potassium pumps start to move and pump things back and the sodium pumps to move and pump things back the other way to to recreate that resting membrane potential and as soon as that flood of ions gets all the way down to the terminal It there's nothing left to flood open and what it does is it stimulates The the channels to open to release the acetylcholine into the synaptic cleft between the nerve and the muscle And that acetylcholine or that neurotransmitter any neurotransmitter could be dopamine could be serotonin could be picked picked a neurotransmitter, right? It's going to just leave that little axon terminal float across that little cleft and stimulate the receptors on the other side and in our case if it's muscles that we're talking about When that acetylcholine travels across the cleft it's going to say hey i'm here Open up your calcium channels And it does the same thing down a muscle To release all the calcium from those sarcoplasmic reticulums But then go to the troponin and tropomyosin and do the whole thing again, right? Is that clicking making sense? Oh, there's lots of videos um But that is movement of ions that is exactly the same as our electrical devices It's just that that's a movement of ions from my body to itself And this is going to be movement of electrons from outside to in So we're going to force that to happen by either depolarizing with ions at the muscle in dc causing that charge to be there because i'm flooding it with negative ions or Stimulating the muscle. I was doing stimulating the nerve To start that action potential then the nerve does the action potential and stimulates the muscle So either i'm stimulating the nerve With ac or i'm stimulating the muscle with dc to do what it naturally does So is that kind of like osmosis like those the flow of like X amount like positive tomato insight and try to get like Sort of osmosis is only the movement of water across the membrane and it's passive if you remember that This takes energy. This is the energy we're talking about to do it So although we don't need ATP to do this We're opening those channels that are allowing it to flow down the Membrane potential so from a high concentration to a low concentration Right. So if I have a ton of calcium outside Or let's do the sarcoplasmic reticulum, right a ton of calcium inside my sarcoplasmic reticulum as soon as I open a channel It's going to go. Hey, I have a bunch in here and none out there. So all the calcium flows out Until it equalizes and then pumps go and grab it and pull it back in pull it back in pull it back in against the membrane gradient Then you said that ac would affect the nerves while the dc affects both muscles Yeah, so the ac is going to stimulate the nerve to do its own action potential Whether it's sensory or motor or both, right? It can stimulate both nerves And dc is going to stimulate the muscle To To not need that nerves Action potential so that whole explanation I just did is the underlined section right there Right separation of charges or ions across the resting membrane potential is maintained by greater concentration of sodium outside Sodium being positive and a greater concentration of potassium inside also positive, but we're going to open those sodium Channels sodium is going to flood in I now get a huge positive charge because i've got sodium and potassium sitting on the inside Of myself so it created a positive charge across that cell so the next one down cathode and anode that is gonna get confusing because cathode and cation don't match I didn't make it don't be mad at me So just keep that in mind cathode Is the side of the membrane that has an excessive negative charge so it's it's got electrons whatever side has more electrons Is the cathode I used to joke and say because cats are negative But they're not but it you know Right, you can see it You can make it work But then it's going to change with the cation so it doesn't really work And anode is going to be the side that has excessive positive charge or a deficiency of electrons So cathode negative anode positive So on this little battery The negative side is my cathode the positive side is my anode cathode and anode right But that's too many words, so they just put a negative and a positive that that anode So in an ac current We don't have a cathode in the nano Because it's ac that's why it doesn't matter if you put your plug in this way you put your plug in this way Right if you have a plug that'll allow you to do that They like to put those fat side and skinny side so you can't screw it up but You could right but now we have a brown so you always have to throw that bad boy in the ground, right? But in ac current it doesn't matter because we don't have a cathode and an anode We have cathodes and anodes in us though because we have negative and positive membrane potentials depending on what part of our tissue we're talking about So The last the last little main thing says when electricity is introduced to a tissue There's a localized effect in the extracellular space and the response to a sustained charge. So if I put a dc current on a tissue And I flood it with negative electrons It's going to have a negative charge sustained within that extracellular fluid Within the tissues And then it also says on there when we introduce electrical stimulation the salt water in our body sodium chloride dissociates into its respective sodium and chlorine excuse me sodium and chloride Which then migrate towards the cathode and anode respectively creating a chemical reaction in the extracellular space that affects the protein density in the tissue This response supports the use of electrical stimulation wound Uh wounded tissue healing The reason it stimulates wounded tissue healing as well as swelling is because there are certain Remember when we were doing wound healing and we had the early proliferative phase and then we had the remodeling phase, right? and in that we had like During the initial like bleeding we have an increase in these cells and then as it starts to heal a little bit Then these cells come in, you know, we move into some mass cells and then we move into other different types of cells that are coming to the region Well, those cells are attracted to a positive or a negative depending on which one they are So if I need someone who is stuck and hasn't moved from that phase one of wound healing into phase two They're stuck in the inflammatory phase and they can't get out of it to get into the remodeling I can start to simulate to pull in certain ones of those tissue factors To force it to move through and start to heal By putting a charge through those tissues and it's positive negative depending on where they are and the whole thing And we'll talk about that when we get into using dc current um, but they They will be drawn towards that area So if I want to have you know, say I have somebody with a pressure ulcer on their heel I'm going to put maybe the negative the cathode there And the anode someplace way far away So i'm still connecting my circuit, but i'm gonna i'm gonna draw if I have a negative charge being forced here I'm going to draw positive ions to that area From my my cells, right because i'm creating a negative the positives are going to be attracted to it So I can create movement of certain tissue factors because i'm creating a negative Environment All right, get up and move you guys are losing it So, our charge is the movement of electrons, right? The voltage is going to be the force that's moving those electrons. So how much, how big are they moving? This comes into Coombs law. So Coombs law say that like charges repel and opposite charges attract. So if I had a plus and a minus, they're going to attract to each other, just like a magnet, right? But you put the two pluses together and they're going to repel. Same thing with electrons, or ions, if I have a positive charge, it's going to be attracted to a negative charge, but it's going to repel from another positive charge. That's what Coombs law says. Don't make Coombs law more difficult. Opposites attract, likes repel. That's all Coombs law is. He got really famous for figuring that out. Damn, wish that was big. I know, right? It's not enough. So both, think of, so, we'll get there. So both is the force that is moving the electrons. Okay, the driving force. So let's look, where's my battery? My battery here, this is a 9 volt battery, right? So it's a DC current, because it's going from negative to positive, and it has 9 volts that move that, those electrons. So that when you look at some of the tiny little button batteries, they're going to have really tiny little voltages. But they're usually moving little tiny amounts of electrons, because they don't need a whole lot. Right? But your car needs a lot, so it has a much higher voltage. So it's the pushing force of your electrons. A conductor is a type of material that permits or allows those ions to move across it or through it. So metal is a great conductor, right? That's why batteries are made of metal, right? Because you put the metal to the metal, you put the metal to the spring, it conducts really well. Water is a good conductor. Saline is a better conductor, because that salt in there, that sodium chloride, has ions. It's already got ions ready to move. So water is a good conductor. We add a little salt to it, it becomes better. That's why when a power line is down, one of the things, right? They always say you have to look at your environment, because you don't want to rush in and do CPR on that person if they were electrocuted by a power line, and you're going to step into that water. Right? Because that water is going to get you. Remember that? Biological tissues, we have some good conductors. The best one is going to be nerve. We have a lot of resistance, or impedance, that's going to slow it, that are insulators. But the nerve is going to be our best conductor. Blood is going to be a so-so conductor, because it's more water, right? We just say that it's going to slow down. Yeah. And yet the myelin sheaths actually need to increase. So the myelin sheaths act just like the insulator around our wire. They're preventing that charge from getting out into the other tissues. It's keeping it in its little hole. So our myelin sheath is an insulator, but our nerve is a conductor. So it's not stopping what's happening in the nerve. That's still able to do its thing on the inside, just like our wire is able. What? If you lose the myelin sheath, it will slow down. Same thing if I were to take this wire and strip it and plug it back in, it also would lose its conduction. But also anything that touched it would get the electricity. Same thing with demyelination, right? It's not going to keep that electrical current inside the nerve. It's going to flood out into the other tissues, which is then going to decrease it from being able to move down. So a conductor is going to allow the flow of electrons across it. So I have a battery here. Who is taking the 9-volt battery and licked it? Does it work? My dad told me it. He's like, this is how you test if it works. I'm pretty sure I got shocked once. Oh yeah, you do. See if it's still good. Yeah. You lick it. And if it zaps your tongue, it's still good. Want me to try it after? No. It doesn't hurt. It doesn't really hurt. It just feels weird. It literally just testing it. But it's because your tongue is free of it. Oh god, all the time. You have to save your heart. No. I just threw it at you. I know what I touched you with my finger. But my skin, look at my skin. I'm not getting a charge across here, right? Because I don't have, my skin is not a good conductor. My skin is a good insulator. So it's not allowing the charges to flow across it. But my tongue, being full of saline, is because of the water. Right? I'm not good enough. I still got too much insulation. You want to lick it? I guess. So an insulator is a material that restricts those movements of ions. So rubber, plastic, and then biological tissues, especially fat. The myelin sheath thing, things made with any lipid. Any lipid. So our myelin sheath is lipid. Our fat is lipid. We've got inside of our bones have, you know, instead of our long bones, we have yellow marrow. That's all lipid. Those are all insulators. They insulate against temperature, against sound, against electricity. They're insulators of all of it. So these conductors and insulators, they're going to be exactly the same when we talk about sound and ultrasound. It does not get any different. Okay, so we have bolts that push the electrons, that drive the force of electrons. The current is going to be how much of those are flowing in one second. How many electrons are flowing in a second? So movement of ions in response to a conductor in response to a volt. So we know we have a conductor moves ions. Well, the volt is my pushing force. So the better the conductor and the higher the pushing force of my volts mean I can get a higher current to flow. Say that again. The better the conductor and the higher the voltage, the more electrons are going to flow. So you're going to get more electrons to move when you don't have anything stopping it and you have a big pushing force. And the number of electrons that are moving per second is amps, or amperes. So think of the amps as the intensity. When you turn that intensity up, you're increasing the pushing force, the volt of the machine. You can't change the conductor because you have the same wire, you have the same pad, the same conductor, but you increase the push that's going to make more electrons flow into the tissues at once. You increased the ampere, the intensity. So this is why, have you guys ever been in a brownout? You did not crop in Los Angeles with me. It's not a blackout. It's the brownout. So a brownout is when the wildfires are taking over Malibu. It's always Malibu. It's what happens when you have too much money and you want to live in a high desert. It's just going to catch on fire, people. Always. So you have these wildfires, you've got, you know, the temperatures are soaring into the 90s and 100s, everything is dry, everybody's running their air conditioners because there's too many people in one little tiny valley and all of your power plants are ugly. So they don't put them close, they put them way outside and so they have to try to pump power from out there to all these millions of people inside here that are dying of heat. And now they're going to be charging their electric cars, although this was long before electric cars. And essentially there's not enough amperage to give everybody the amount of energy their houses need. So you would have your lights on and then all of a sudden everything would dim. And I think it would just, they would get brown. They wouldn't go out and then maybe they would come back on. It was like a little dip and they would come back on. That's a brownout, right? And then we're going to say rolling brownouts today because it's like we're going to decrease it to all you people and it's just going to roll through the system because we don't have enough energy. We don't have enough amps to go to everybody. We're only making a set number and you guys are demanding a higher number. We don't have it. So either we shut it down completely or we decrease it. But the lights are meant to run on a certain intensity. They're not meant to run on a lower intensity. So they would dim. But it's also the same thing as your dimmable lights, right? You're decreasing the intensity, the light dims down. You increase your intensity, the light goes up. You're changing the amps. A higher amp or a lower amp. More electrons, less electrons. Did those make sense? Understanding amps? Yes, no, maybe so. Can there be a current? So if there's no voltage? So that's your grip sitting in the microwave that's not turned on. You need something to push those electrons. So you can't have any amps if you don't have the engine to push them. So watts is just a measure of work or power. So that's going to be like when you look at your light bulb and it's 60 watts. That tells you how much power it will need and or put out. So a higher wattage light bulb is going to take more power to put out more light. But a little night light that's like maybe a 5 watt is going to take just a tiny bit of power. But only put out a tiny bit of light. So I feel like light bulbs are the easiest to understand watts. Because we see that all the time. Well at least if you change light bulbs you see that all the time. Yeah, so watts is the amount of power that it either takes or uses or produces. It's how much oomph it has. So in a light bulb the higher the wattage the brighter the light. The lower the wattage the dimmer the light. The big like football stadium lights. Yeah, yeah. Tons and tons of energy to go to those. But also so bright you can light a football stadium. Or a light bulb, a little night light. Not even good enough to see that step before you turn. Oh you can also think about it like the amount of energy we can store creates how much light we can produce. So like look at those solar lights. You got the little solar lights along your walkway. They don't get very bright because they're not able to store a whole lot of watts. They're not able to store all of those electrons which is all they're doing right. They're taking the energy from the sun. They're converting it into stored energy. It's what your solar panels do. And then they release those electrons to power the lights. When the sun stops coming in. Right. So they're converting the photons from our sun into electrons to make a little stored battery. They're charging up a little battery in there and then they're turning it back into the light. But because they aren't getting very much they're really dim. Right. They don't do a whole lot. When you put solar panels across your whole house. Now you can charge your whole house because you have big solar panels. So the wattage is. Everything has watts on it. So you can flip these things over. This has 31 watts. 120 volts because it's going into my outlet. This is a 120 outlet. It's 60 hertz because it's in the United States and we run on 60 hertz. And it's 31 watts. So right there on that little tag. So 120 volts. That's the push power for the electrons. The 60 hertz. That's how fast that AC current is alternating. And then 61, 31 watts. How much energy that's capable of producing in terms of heat. Because that heats up ultra sound gel. Or how much it's going to need to heat that up. What was the one that was 110 and 220? So that's the volts. Okay. That's what you're saying. That was 110 because it's plugged into a 110 outlet. So all of our outlets in the United States are 110. Okay. Except for dryers and hot tubs. So our actual electric is 110 but like wouldn't it be 110? No, it's a 120 outlet. 220. It's 220. 110. It is 110. That's 120. So I think it's just going to answer. That's probably a max at 120. Maybe. Yeah. Okay. An extension cord plugged into an op. Like my box plugged into the extension cord. And I think it messed up my phone. Is it because they're all different numbers? Potentially. The extension cords are terrible. Don't use them. Sometimes you have to because you don't have enough plugs. Right. My dad, the electrician, would yell at you. And it's around my bed. So I have to find out. Oh, it's going to make you feel good today. You need to come and make extension cords. You have one around your back. The extension cords are meant to work with so many different things. And the amps that go through it, the watts that go through it are variable. You don't know. So you have to look to see what that extension cord is rated for. That's the only thing for that. So yeah, it's a 110 outlets. It's always 110 in terms of its volts. And it's always going to be 60 hertz because it's in the United States. But how much watts are going through it, how much amperage is going to it, that can vary. Because I plug my phone in and it goes from like zero to 10. That's probably more your phone. Well, but I think I did that from the extension cord. Extension cords will burn your house down. That is horrible. It has a lot in my room. I have one that plugs in my AC conditioning unit, my refrigerator, my computer. All the big shit. It's plugged into one cord. All right. I don't think... Do we have more questions on that? She's like, you're going to die. We've already talked about that, right? That's the number of pulses or waves. I don't want to say pulses. But waves per second that are happening. So our AC current, how many times it fluctuates positive to negative per second. So one time, one hertz. Sixty times our outlets, 60 hertz. Hertz is frequency. HZ, big H level Z. I have to have it to my forehead. It slid into my eyeball. So again, on our example, 25 ups and downs in that one second is 25 hertz. Just because it goes for two seconds doesn't make it 50. It's still 25 hertz because it's only per second. It's always per second. Like miles per hour. Like miles per hour. Yeah, exactly. Always AC because it has to happen. How many times it's alternating in a second? You can have pulse per second in DC, but it's not going to be a frequency. It can be pulses, but it won't be a frequency. It'll just be boom, boom, boom, boom, right? But always positive, positive, positive, positive. Negative, negative, negative, negative. It's always alternating. AC is always alternating. That's the name. Alternating current AC. It can also be pulsed. It can be solid, it can be pulsed, yeah. Okay, resistance. So resistance is something that is not just an insulator. So we have insulators that resist the flow of electrons across it. But a resistance is something that is going to slow the flow. It doesn't stop the flow. I can grab this cord and not be shocked at all because it is absolutely preventing the flow of electrons into my skin, right? It's an insulator. My skin is a resistor. It slows the flow of electrons, but it doesn't stop it, which is why we can put electricity through our skin and it's going to go through our skin and into our body. But it's going to slow it. It's going to impede it. So it will move through, but not as well. So the following biological sources are high resistance. Skin, adipose, hair, fascia, ligaments, callus, because it's just really thick skin, bone, tendon, and scar tissue. So the current can flow through all of those, just not very well. It's going to slow it down. More than 99% of the resistance to current flow in the body is the epidermis, the top layer of skin. So once we get past that top layer, it's going to blow much nicer. Why do you think that is? That gets even, I can think of those nerves really well. Those are going to be good conductors. It is. But why is it better once we get through? What's down there? Yeah, water. You get water, right? I do not have water right on the top layer. It's purposefully not full of water. It is, right? It's got that oil surface. It creates that oil to be waterproof, to keep my water inside and to keep the outside water outside. So once you get past it, now you have a good conductor with water, not to mention nerves and other things that are going to do it a little bit better that are under there. We've got nerves. We've got blood. We've got water. We've got an extracellular fluid. All of that is water. Well, the nerves are a nerve. Right? There still might be some resistance in there. Because maybe I have some scar tissue or adipose, but adipose has water. So it's going to allow it to flow, but maybe slowly, but not as much as the epidermis, the top of the skin. So if I'm looking to put something on a patient and I look at them, and maybe we're doing knee, right? And they just had knee surgery, and I'm trying to put some electrodes, and I'm going to do two. I'm just going to do pulse biphasic, two electrodes. I want to cross his pain, which is in his knee. I'm going to put one like distal quad and one maybe like tib anterior, right? So get across those nice muscles. But maybe he does something physical for a job, and he has a big callus on the front of his knee. I'm going to just move my pad a little bit so I'm not touching that callus, because on thinner skin, it's going to do better than on thicker skin. We're going to see this really clearly when we do ultrasound, and we are ultrasounding the different tissues, and I purposely make you do the heel, because nothing will stick more than the heel. Like literally, it's like easy, easy, hazy, easy. And it literally like sucks your sound head to the heel. It's the callus, right? Because it's really strong resistor. It's the thickest part of our epidermis. So again, if I'm thinking about on the palm, if I'm trying to treat someone's palm, and they have calluses, I'm going to avoid those calluses, because it's going to have too high of a resistance, and I'm not going to get potentially my desired effect. So you're going to go to softer, thinner skin, where you're going to have less resistance. You might have to use a higher amplitude, increase that intensity, for it to get into the tissue. But also, we have nerves, right? Our skin has a lot of nerves. The nerves might be like, that's too intense. I'm feeling too much of that. That's too much for me. And so then we can't go so high. So you end up kind of having this challenging balance where I want to get more in to get that muscle contraction or whatever, but they can't tolerate the sensation. But if I move to an area that's thinner, I won't have to put as much intensity in to get the same desired results. So the two bolded sections down there. Higher water content decreases the impedance and increases the conductivity. That means that somebody who is well-hydrated is going to have a better conduction of electricity, be internal or external, electricity that they're sending themselves or electricity that I'm putting in externally, than somebody who is dehydrated. They're not going to have that same water content. They're going to have a higher impedance, and it's not going to conduct as well. So your patient who's coming in post-op, who reacted horribly to the sedatives and maybe was super sick and throwing up and became dehydrated is not going to respond as well to electrical stimulation if they weren't dehydrated. If they were able to take in fluid and maintain a normal amount of fluid balance within their body. And that's going to change on a day-to-day and sometimes minute-to-minute process when we're working with our patients. Because it's hard to control, right? It's one of those things that's really hard to control as everybody gets out their water bottles. So low water content increases the impedance. So the impedance is going to be just what the resistance does. It impedes the flow of electrons. Don't let that word scare you, right? Impedance is literally impeding the flow of electrons. That's the same thing that something that is a resistor will impede the flow of electrons. So bone, tendon, fascia, those don't have as high of water content, which is partially why they have more resistance. Not that they don't have any, but if they don't have as much as say muscle and blood and nerve. Fat does have water content, but it also has a high lipid content. And as we saw in the insulators, lipids are going to be what is a good insulator. So fat having that insulation property and the low water content makes it a really high resistor. So again, thinking back to a patient, if I'm trying to get quad activation, and maybe my patient has more adipose tissue right here, and they carry some of that right there, and it thins out a little bit below it, if I move off of that adipose, I can get a better muscle activation than if I go over the adipose. So sometimes their placement might be imperfect for where the nerve is going to activate, but better because I'm avoiding a resistance. Whether it be a callus or adipose, don't go right over bone, because it's not going to, first of all, what are you going for? And it's not going to conduct it very well. It's not that you're going to harm anything. It's not going to harm it by going right on top of the bone, but it just may not give you the desired results that you want. Accommodation, also called acclamation, is just decreased sensitivity and excitability of the tissue. Essentially, you get used to it. Your body stops responding to it. We have accommodation to things constantly. If we didn't have accommodation, you would be so overwhelmed with all of the stimuli that your brain wouldn't know what to focus on. So right now you have accommodated or acclimated to a lot of things, like the sensation of your foot in your shoe. But now you just felt it because I brought your attention to it. But up until that point in time, you had not thought about that. It was gone. You had probably acclimated to the sound of the hearing. But now maybe you can hear it because you're being brought back to it. You have accommodated to the sound of your heartbeat in your ears. Thank the dear Lord. Because your heart rate is so high in your ears, you should be able to hear it every beat. Sometimes we do, but thank goodness we don't. Or if we're in a really quiet, then we can start to hear all of our joints creak and we can start to hear our heart rate in our ears. That's why people don't last long in sensory deprivation because they start to hear all of those things that we don't normally hear. But when we're talking electrical and stimulation, accommodation is going to undo what we are going for because the body is going to stop responding to the person. So we're going to either have to increase the amplitude, turn up that intensity, or change the current. Change the frequency, change the rate, change something about it that the body doesn't expect to happen. Does that make sense? Any questions on the accommodation at all? You're welcome. Okay, capacitance and impedance. We talked about impedance, right? Something that's a good resistor impedes the flow of electrons. We've already used that word, so hopefully it kind of makes a little sense there. So it's a form of resistance, but specifically, impedance is a frequency-dependent resistance to flow. What that means is the higher the flow, or the higher the frequency, the higher the impedance. It's why sometimes you can, if I were to come to this table, and I pull it really hard and fast, maybe I don't move it, but I pull slow and I can start to move something because I'm not impeding it as much. But you give it that hard, fast push and it's like, no. Stretching, we stretch a tissue nice and slow so that the body doesn't react and contract against it. It allows me to get that stretch deeper and deeper and deeper. But you go hard and fast and the body responds to that by contracting. Same thing with various types of impedance in our tissues. We start the intensity low and work our way up to decrease the body's reaction to the impedance. We don't want it to stop that flow because we gave it too much too fast. That's why that ramp cycle, or that ramp on the Russian or any of the pulsed biphthasic, that ramp on, ramp off, helps reduce the impedance of the tissues, that resistance of it. In capacity, we don't deal with capacity terribly much with anything that we do, but just so you have an understanding of what it means, it's the ability to store an electrical charge. All of our nerves, they are storing electrical charge because they are ready to have that action potential happen. They are sitting at their negative resting membrane potential. That is their stored charge. You have, this is a fun fact and I just think it's frickin' ridiculous, you have enough capacitance in your body at any given moment to start a car. But if you were able to pull that out, you would have no stored energy, you would be dead. So we can't do that. And we can't just discharge our energy at will because we're not super human. But that's how much capacity we are storing at any given moment, the same as a car battery, but you get one start. We don't need it. But so we do store it, but it's not really a system that we work with or work on much. But it is how we are able to use AC current to stimulate the nerves because they have that stored capacity within them. But we're not going to be changing that per se. And then I put down at the bottom, gels and the adhesives from our pads are going to help reduce or decrease that impedance between the skin and that electrode. Water is a good conductor. Air is an excellent resistor. So we want to eliminate air by putting the gel or the electrode that is not dried and covered in skin cells because that is literally just taking something with a good resistance and putting it on to try to conduct through. It doesn't work, right? So that's why you have to look at your electrodes to see, are they covered in crap? It won't work because you're going to literally be taking that resistance and putting it on to the skin that already has resistance. We're not going to have good conduction through it. Makes sense? Feeling okay about these words? It's a lot of vocabulary, I get that. Find your inner home. We can do the home slot. It really, it makes sense when you think about it. Just like combs, right? Opposite charges, it's like, yeah, duh, I got it. Also, you're going to get it, I promise. So this is the relationship between the current, the voltage, and the resistance. So we know current, that's the movement of electrons. The voltage is the push, and the resistance is the slowing. If I increase my voltage, I increase my push, I'm going to increase the number of electrons that flow. I'm going to increase my current, right? Push harder, more electrons. That makes sense, right? Decrease my push, decrease my voltage, decrease my current. Less push, less electrons. So far so good? All right, now let's talk resistance. I increase my resistance, but don't change the voltage. I'm going to decrease my current. I'm slowing it down. I increase the resistance, I decrease the speed. This is when you're on your bike. Don't change your gear. You're pedaling away. You maintain your same pedals, but now you're going up a hill. Uh-oh. It's harder, right? You're slowing down, and slowing down, and slowing down, because you've got more resistance. You're going to slow down. You go downhill, though, decreasing that resistance, and you're like, whoo, down the hill nice and fast, because you've decreased the resistance, you've increased the flow of electrons. Question? Does that feel okay? Stand up and move around for a second. So this we're only going to spend a little bit of time on because we only use this in two sentences. We use this with iontoparesis and we use this with DC current and wound. So I'm not, we're not going to spend a ton of time on this because there is, I used to go into a lot of anodal stimulation and cathodal stimulation, how we can do nerve blocks and all that stuff, but honestly it's not used clinically and I don't think this is the kind of material they're going to be asking you on the NPT so both of those it's not really as important to focus on. But just so and I kind of mentioned you know the cathode is the negative pole anode is the positive pole. You guys I can never remember that. Which one is red and which one is black? I never can remember but one is red and one is black and when we look at our iontoparesis units, I think I even took a Sharpie. Oh these are my brand new ones, I didn't mark on these ones because these are brand new, well that was my other one. Sharpie, that is positive, is that what you said? So on this, so does it matter when we put our other electrodes on that are our AC current because it's alternating. There is no positive and negative, it's literally positive, negative, positive, negative, positive, negative, positive, negative, positive, negative, positive, negative. They're both, right? But in ionto, which is a DC current, it matters, right? And so if I have, this is my positive, my red, so this is going to be my anode and my black is going to be my cathode, my negative. If I have a chemical that is negative, I'm going to put my negative on top of that and my positive on the other pad so I push negative to negative and they repel. So this matters on a DC current but that's the only time that our anode and cathode matter, right? So here's where it gets a little bit weird, because I think it's weird. Cathodal stimulation, anions are discharged into the body. Now I said a cathode is the negative pole but anions are negative and anodal stimulation, cathodes, positive, are discharged. But that is exactly the opposite of what the names are. And I told you it's opposite and I didn't make it. So cathode is negative but releases anions that are negative and anode stimulation relieves cations that are positive. It's frickin' ridiculous. I'm nothing's happening. You know you have that axon down there and some extra cellular space and it's pretty much, we have that negative resting membrane potential inside of our axon. So we've got a little bit more negative than outside of our cell. We have a little bit more positive, right? You know we turn on my, so this is cathodal stimulation, so I'm turning on the negative. Cathode, I'm releasing anions that are negative. So those, all those negative depolarizations right there, those are anions. And the way that the reason in my brain, the reason that cathode releases anions is that they're going to be attracted to the anode. Anions go to the anode. So they're opposites. Cat ions go to the cathode. So they're opposites, right? Because opposites attract. Can you get on board with that? Kind of feel that. So don't get too worried that they're the opposite names. Just remember anode and ions, they're going to attract to each other. So they have to be opposite charge. So here we're depolarizing that space right there on the right hand side and we're hyperpolarizing the anode side, making it so we depolarize the nerve one direction and we block the nerve the other direction. So if I'm using this on a sensory nerve and I block it going to the brain, it cannot sense stimulation. So I can illuminate pain. But if I'm doing this over a motor nerve, I can create muscle activation by doing this cathodal stimulation because I can depolarize going down towards the muscle. But I'm not going to get much of that, right? I'm going to get one shot and then I have depolarized it and I have to turn it off to allow it to repolarize. But if I'm trying to block nerve sensation to the brain, this is great because I can block it for as long as I need. This is the one I was talking about for for dental work because it can't sense the pain, can't sense anything because I have blocked that nerve from being able to sense the stimulus. I mean it's the same direction, right? But the brain is at the left side and the muscles at the right side. So if I'm blocking it like this shows to the anode block, I'm blocking the brains being able to sense it, but I'm sending it to the motor. So it depends on what nerve you're over. If you're over a motor nerve, you will create a muscle contraction. If I'm over a sensory nerve, I will block the sensation. Or if it's a mixed nerve like all of our peripheral nerves, right? I'm going to get a motor, but I'm also going to block a sensation at the same time. And then you can switch it and you can stimulate from the other direction. It's going to do the same thing, right? Because it doesn't matter. My nerve doesn't change on here. It still stays negative positive. It's still an anode block on both ways, so it doesn't really matter as long as you have it set up that way. You have the anode, the positive going towards the brain, the cathode negative away. It works exactly the same. So in this case, I would put the pot, like if I'm trying to block my wrist hand pain from getting to my brain, somewhere up here, higher, I'm going to put my anode. Somewhere lower, I'm going to put my cathode blocking that nerve sensation back up to the brain. It just has to physically be that side. DC stimulation only. It's the only time we're getting an anode and cathode. Questions? This is just talking about the difference between how our brain works and how a motor, you know, an electrical device works, right? Electrical stimulation versus the brain. They are not the same, huh? The brain and electrical stimulation are not the same. So looking at the central nervous system first, the brain, the way we recruit muscle is we do this small type one motor units first and then fire bigger and bigger and bigger and move into 2A, 2B until we have what we need, right? Small first, small fiber neurons to large fiber neurons, small motor units to large motor units. This is really effective because I don't want to have to use more than I have to. It's energy conservation. Why use a big motor unit with a lot of nerve fibers if I can get away with the same thing with a smaller motor unit. Plus, I don't want to have to pick up something and go, whoo! Right? When all I need to do is pick it up. I don't want to use more nerve and more motor units than I have to. So you start little and you ramp up. Exactly the opposite of what we get with electrical stimulation. The bigger the nerve, the easier to stimulate. So the big nerve, the large motor unit, gets fired first. The smaller motor unit gets fired last. This is why we can't just hook somebody up to a machine who has a spinal cord injury and have them function perfectly normally. Because we're not firing the nerves the right way. They are gonna walk like a robot because they are moving like a robot because it's big to small and not small to big. It's beautiful in movies, doesn't work in reality. Where science fiction doesn't mimic life, sorry. The other thing our central nervous system does, we kind of talked about it, right? It fires one, fires two, it fires three. It goes back to one, to two, to three. It's asynchronous. They overlap a little bit as one is coming off, two is moving on. As two is coming off, three is moving on. So it's asynchronous firing in order to maintain a contraction and keep a nice steady, smooth movement. Electrical stimulation, all at once. One, two, and three all at once. I can't pick one, two, or three. I get all three at the same time. And that will continue to happen as long as the stimulus is there and the ATP is there, the glucose is there, every, you know, that all the things required for that muscle contraction are there or all the ions required for nerve conduction is there. It will fire everything at once. We cannot pick and choose what units were firing. The last difference is when the brain sends the signal, it moves from the brain and away, right? It's always moving in one direction. It never goes backwards. But when we stimulate with an electrical device, I stimulate at some point in the middle of the nerve, it goes in both directions. So it goes up the nerve and down the nerve at the same time. So you could argue that if you stimulated at the spinal cord, it would only go down the nerve. And that would be true, right? But we'd have to be at that axon terminus of that nerve in the spinal cord in order to make that happen. And we are not at that point yet. So they are not the same. Okay, this is the last thing we're gonna do and then you're gonna try this. You're gonna play with this today and feel different things we didn't have time to feel yesterday. I mentioned that we would go over this constant current and constant voltage. So when you're setting up your machines, you can see CC and CV. Constant current versus constant voltage. So constant current, the machine is going to produce the amount of current that goes out has to come back, right? Because it's a closed loop. So it's gonna vary the voltage. It's gonna vary the push depending on the resistance that it encounters. The machine is gonna adapt, which is really nice because I don't know if this time I put it over this little tendon that maybe last time I missed. So that's why we don't care about the number that we turn it up to. Because if I move that pad just a little bit, I might have it over something with a higher or lower resistance. So I might need a higher or lower intensity to have the same outcome. But as the machine is running, impedance can change. The body can change as it fatigues, as it dehydrates, as it rehydrates, as whatever's happening millisecond by millisecond, that impedance can change in the body. And the machine, if it's constant current, is going to vary the amount of voltage so that what goes out comes back in. Okay? Where constant voltage, it's gonna send out the same volt regardless of what comes back. So the machine is gonna send out a voltage with a current. It's not going to change the voltage even if that current drops as it's coming back in. So it says in the last thing, does not accommodate to changes in skin impedance or muscle contraction causing impedance. If I'm creating, if I'm creating a muscle contraction, the more it contracts, the more resistance it will have. Now constant voltage is not gonna accommodate for that. So this is you driving with your foot pushed on the gas pedal at the same point. You go up the hill, you slow down. You go down the hill, you speed up, right? Kind of like that bike analogy I said. You're pushing the same amount on the gas. Where if you're in your car and you put on cruise control, it happens to be the same letters. It's constant current. It's going to change how much energy is put out to go up and down hills to maintain the same speed. So they feel different. Constant voltage tends to feel more comfortable but does not acclimate to what's happening, which means I might lose that contraction if the impedance increases. Where constant current is going to change all the time, so it might be less tolerable to the patient, but I'm gonna hopefully maintain that contraction or whatever it is throughout the entire treatment. So what I want you guys to do is set up a machine. Let's set up either Russian or pre-mod. Get a contraction. Feel the difference. Set it up with constant current and set up with constant voltage and feel the difference as it runs for a few minutes. Okay, that's what we're doing. As soon as I hit like, started powerpoint, and then started, I definitely noticed it. He's better than the guy banging on the wall in Dana's class. I will throw up, but then it lands on you again, and I don't want to scare you. No, there was a guy working on the wall behind us in Dana's class, and he's like hammering hard. I was like trying to knock that wall down. It was his left shirt. Did she go, I mean, excuse me. He was like, oh, I have no idea. Yeah. Teaching. Teaching. Okay, so then constant voltage. What did you guys think about that? I have more of a contraction. Say that again. I have more of a contraction. Okay, better contraction. I felt it less as I contracted it stretched. Yeah, so you can move out of it and not have a good contraction or intensity. Because that's the entire purpose, right? It's maintaining the same push, but not changing the current to match any resistance that may be happening in the skin. So especially if you have somebody who is very sensitive, doesn't like the E-stem, is nervous about the sensation of it, you might want to go constant voltage, but knowing that you may not over the length of time. We only did it for a few minutes, right? But if you're going to have this on for 20 minutes and working on quad control and doing exercise with it, knowing that during that time frame, it might not be giving the same type of attraction the whole time. The contraction might come and go and might fluctuate a little bit. But if you really need to make sure that you're getting the same contraction regardless and they tolerate it, maybe you go constant current, especially if it's on a less sensitive place. All of you had it on your forearm, which was really sensitive. But if you put it on your quad, which has less innervation to begin with, might be more tolerable to do constant current and increase the amplitude because it's not as sensitive as our upper extremities. Maybe, right? Everybody's different though. Some people will tolerate one better than the other. So although I'm making these generalities and saying constant current is less tolerable, but better contraction, constant voltage, more tolerable, but very well contraction, you have to really look to see what's happening in front of your patient. And you saw how you can try to switch it during the treatment. See, that's not tolerable. Let's try this. You just change your intensity again. Right? All right. Any questions on that? Feel pretty comfortable on constant current, constant voltage? I spent more time on it with you guys than I have in your class because it's been a confusion and I want to make sure we have it just a little bit. But that's really a clinical change that we can use easily and frequently while treating. So I just want to make sure that that's up there. And maybe in a lab practical, you're going to tell me why you're picking that. I picked constant current because I want to make sure I'm maintaining that big contraction as long as you tolerate it. Right? Because you're worried about the sensation. So DC, direct current. So this is going to go into, I believe it goes into each one of our, yeah, each one of our types of stimulation. So now we're going to get out of just the theory of everything and looking at the individual ones a little bit deeper. Okay. So DC current, we really only use this for two things. We're going to use it for ion to for races and for stimulation of de-innervated muscles. You also can use it for blooms. So that really should be up there too. So three things. The main thing with DC current is we are creating an electrical charge in the tissues. So we are creating a negative or a positive inside the tissues depending on where our cathode and anode are. We're creating both. Right? But if I'm trying to get a negative in one area, I need to make sure that I'm putting the cathode over that and putting the anode someplace else. But you're going to create a negative and positive charge within the tissues under each one of those poles. And we're going to use that to either drive medication and ion to for races or because of that charge to force that muscle contraction in that de-innervated tissue or bring in tissue healing factors for blooms. What is a de-innervated? No nerve to it for some reason. So spinal cord injury, nerve transaction where we cut the nerve, a crush injury where the nerve is damaged, MS, Guillain-Barre. That's an interesting thing. So Guillain-Barre and also myasthenia gravis. Two diagnoses that our advisory committee last night said they're seeing a huge increase of both Guillain-Barre and myasthenia gravis. Things that we kind of like, yep, these things exist. Yep, right, it looks just kind of like MS but resolved. We don't go into it terribly deep because it wasn't something that we were seeing a lot of. But apparently it's been a huge uptick lately, which I find to be really interesting. And the other one that they said that they're getting consults on in the hospital all the time. Alcohol withdrawal. They're like, we're in those rooms constantly because of all the things that are shutting down because of it. And like, never something I was ever taught in school because it was not anything that we dealt with. Right, that was physician and nursing. We didn't ever go in there. I didn't want to go in there but now we may have to start rethinking that because the amount of systems that are affected with that. But Guillain-Barre definitely is going to be one of your de-innervations. Yeah, that's about it for drug current. In order to get these though, in order to accumulate those ions, this is actually an important thing. You might want to like star or something. In order to accumulate the ions, it has to be constant. If you have it pulsed, then you're going to accumulate ions and then they're going to dissipate. And then accumulate, accumulate, dissipate. That is not going to create that net charge within the tissues. Can you see that view? Yeah. So in order to get that accumulation of ions within the tissues, it has to be constant. It cannot be pulsed. Pulse is going to accumulate a little ion and then when it's off, when it's on that off pulse, it will dissipate the ions. So if I'm trying to accumulate them to push medications through or to bring down various inflammatory factors, whatever, to heal a wound, and I let it dissipate, I'm not getting it. I'm not doing what I want it to do. Yeah, DC current has to be on, no pulse. But if I'm using it for muscle stimulation, I want, maybe I want that break in there. So I'm not trying to accumulate the ions in muscle stimulation. So that one can be pulsed. But if I'm using it for a wound or ion toe, it has to be constant. Can we understand why on that? But if it's muscle activation, like for that de-innervated muscle, then I can give it a little break. I can allow it to bring those ions out, move those calcium ions back into that sarcoplasmic reticulum, give it that little micro break, and then back at it. So if you give it a break, would that mean it would kind of reverse? Like, since you're pushing all the negative, if you give it a break, it's going to switch. It's going to go back to like a neutral, right? The ions are going to, the positives and the negatives are going to move their way around to be more at equilibrium. And in these cases, we wouldn't want that to happen. Right. We want that negative or positive because I'm trying to push that medication in, and that medication is charged. So once it's in, I don't care. It can turn it off. Medication is already in there, doing its job, right? Okay. IFC, interferonational current. This is why every time I wrote things about the ICF, I wrote IFC, because I'm so used to IFC and that ICF. So many times I get it backwards. You remember the ICF? International classification of function. Not interferonational current. Okay. So this is, the only way you can do IFC is with two channels, four electrodes. You have to have this set up. You cannot do IFC with a single channel. Two channels, four electrodes. And those four electrodes have to cross their currents. So as you see here, channel one being the blue, it's connecting its circuit this direction, and channel two is connecting its circuit this direction. So they're crossing somewhere in the middle of the tissues. And you can see that channel one has a lower, slower wave pattern than channel two. They have to be different. It doesn't matter which one is higher and lower. They just have to be different. Okay. So in this case, they have channel one at 5,000 hertz and channel two at 5,100 hertz. And so the difference in those is 100 hertz, right? We have a 100 hertz difference, which is going to give us what we call the carrier frequency. So it's creating that secondary frequency in the tissues as they combine and go opposite of each other. So when they are in phase, when each one of these beats, each one of these upticks, right, they're both going into the positive. When they are in phase and going together, then it's going to increase the amplitude within the tissues. Okay. So you've got some coming here. You've got some coming here. They add together. So if both of them are at an amplitude of two, they're going to add together and have an amplitude of four. So the beauty is I don't have to push four through my skin with that impedance, but I get it in the tissues. So I have a lower impedance because I'm not driving that current through the skin, but I get a bigger response in the tissue. So it's a bigger thing for your buck, right? So when they're together, sorry guys, they're going to add. When they're out of phase and they're completely opposite, they're going to cancel each other out. So what that does is it kind of creates three different frequencies within the tissue. You have a frequency of channel one, the frequency of channel two, and this carrier frequency that is a third frequency. And what it does is it's varying the amplitude, how much is in there, how strong it is. And because of that, it's very hard for our body to get used to it because it's never the same. If it's always two, peaks of two, peaks of two, peaks of two, peaks of two, peaks of two, peaks of two, and a point over again, I can start ignoring that peak of two. My brain's going to be like, yep, I got you. Feel that pain's over here, right? But it's peaks of two, peaks of four, peaks of zero, peaks of two, peaks of four, peaks of zero. My body's like, wait, what, what, what, what? Okay, no, I can't get used to any of it. So I'm thinking about this and I'm forgetting about that pain over there because I can only think about this thing that's changing all the time. But your patients are going to feel this like it's going up and down. It feels like it's massaging. It feels like a wave. Like there'll be all these different descriptors. And it's not the individual frequencies, the carrier frequencies that they're feeling. That's going to give them that wave feeling. I would feel about that. Yeah, so that's the beat is equal to the difference in the original frequencies. I'm just going to give them one third carrier frequency. Okay. Okay, got it. So we have circuit one, the same numbers as our other page rate. 5,000 Hz, 5,100 Hz. So the difference between them is 100 Hz. So if you were to look at, so this is where they are opposites of each other, right? This is down, this is up, so it's right at zero. And then here, they're up and up together. Oops, up and up together, right? So now that's my largest amplitude. I'm adding it together. So now my amplitude went from zero when they were opposites to the max over here added together. And it keeps doing that. So if you were to take this frequency and draw it out, that's going to be your frequency of 100. It's a fake frequency. All right, can you see what I'm talking about? So this is your frequency right here. Right, see how slow that's going to be compared to this 5,100? So it's just this really slow frequency in here. That's the carrier frequency. Still not feeling it, Abby. Can you see how it makes its new frequency? So it shows the peaks? Yeah, so the peak is going to come up and down and up and down. So it cancels out to nothing. And now I'm at maximum and then maximum flow because they're adding together at the low. And here, I've got a little bit of positive, maybe a little bit of negative. So it's just adding, like looking at the peaks and valleys as it's moving through in this new amplitude. So it's been pulling at a fake frequency because it's not really a frequency moving through, but it's a perceived frequency in the body, this frequency of increase and decreasing amplitude. So it's not movement of electrons at this frequency. But it's that perceived frequency of a change in amplitude. So is that kind of like what your body feels? Yeah, it's exactly what your body feels. So then would that like the max high be the end phase and then the two bottom increase? Like the lower it could be, would it be the out of phase? No, out of phase is when they're opposites and it's going to be zero. They're still in phase, but in phase in the negative or in phase at the positive. When you say it's what feels, if that is what it feels like, it's zero. Yeah, I mean, if you think about it, it's like you're feeling this buzzing, right? But then you have this wave and the wave is up and down and up and down. And at some point you're not feeling it. You're feeling no wave. And that's when they're out of phase, right? So it's a perceived frequency. But this is why IFC is the most tolerated of all of the types. And you can do this with a tense unit. You can do this with a big fancy Chattanooga. You just need two frequencies that are slightly different and crossing. This peak where it goes up, it means that... Hold on, I'm going to use my mouse. So see that the circuit one here, I'm at my peak right here. And I come down the same exact time. Circuit two is also at the same peak. They are in phase with each other. So they add together where normally their amplitude was two. Now they add together and they have an amplitude of four. But when they're out of phase, like this isn't a perfect out of phase, is it? Oh no, this one is. So this one, the peak is up here. So circuit one, I'm at my peak positive. But circuit two, I'm at my peak negative. Now they're canceling each other out perfectly. And everything in between, they're just slightly going the opposite and slightly going together to make it get slightly bigger, bigger, bigger till we hit the peak and then they're going out of phase, out of phase, out of phase. And then they work their way back in phase and then out of phase. And when that feels like one second. If it's 5100 Hz, no. Didn't you say that I was like, yeah, one second. Well, I mean, 5100 Hz means that, or 5000 Hz means that it's doing up, down, 5000 times in one second. That's like a million seconds. So yeah, you're seeing a super tiny fraction. So is that what kind of creates the buzzing feeling? So, I mean, the up and down, the alternating current can create that buzzing feeling. But when you put on IFC, you'll feel that buzzing and this extra thing. And it's and that extra that we're going for. The carrier. Yes. Slowly getting it. I like it. So, pre-modulated, this looks just like this bottom one, right? We're getting this same carrier frequency. The biggest difference is pre-modulated, we're using one channel, two electrodes, and we're faking this carrier frequency. And it's faking it by sending in increasing and decreasing amplitudes. So we're in IFC, I only have to send two amps in through the skin, through each one of the channels, and I get a resultant four amps in the tissues. Pre-mod, I have to send in four amps to get four amps. Nothing is adding together in the tissues. So if somebody can't tolerate that, you're going to get a lower amount of intensity than they would with IFC, because the skin is going to be my impedance. That feel okay? So it looks the same, it's trying to mimic it, but with two channels. With one channel, sorry. I was correcting myself as drinking and I didn't have the ability. Michelle, what was it? With the IFC, if you still want to get to that four, which is why you're like... You're going up as high as they can tolerate, knowing that they're getting more vein for their buck in the tissues. You still turn it up until they don't feel the pain. That's the whole key. I want this to be higher than the pain, so tell me when you only feel this. The key is though, I don't have to turn it as high before that's all they feel. So I'm not hitting the resistance of the skin as much. Where in pre-mod, I will have to turn that amplitude up higher, because I'm not getting that bonus of adding things together in the tissues. So sometimes you could run into the issue where you're stopped by the sensation at the skin before you're stopped by feeling that instead of the pain. That lotion is so strong, I can already smell it up here. It's stress relief. Okay. So I'm just going to put some bergamot in it. I can't stand bergamot. Eucalyptus. Yeah, it's eucalyptus-y. So when you're lifting the dial, is that the amplitude? Yes. So this amplitude, you have to turn it up higher? The same amplitude you're putting in is what they're getting in the tissues. Nothing is adding together to have a higher amplitude. I see it as an added amount. Yep. So theoretically pre-mod would have to go twice as high. To have the same outcome. But it depends on the patient. Yes. Yeah. All right. Any questions with that? And you see that they have the typical hertz here? I think that's supposed to say 1,000. I think I missed a zero, because it's not 100, and I don't know what that would be. So it's 1,000 to 10,000 is your typical frequency. And on IFC, it's the same thing. 1,000 to 10,000 typical frequencies. Most of the time, you're going to see something in that 2,500 to 5,000 range. And like on the rich Mar, you can't change that, right? I think it has high and low. I don't even know what that is though. What is high? What is low? It could be 1,000. It could be 10,000. I have no idea. On the Chattanooga, you can adjust the frequency within a certain amount. And I don't remember if you can change it on the CompoCare. I think you can. But they're all going to be a little different in how much you can change that. Okay. Unlike pre-mod and IFC that have a frequency that's somewhere between 1,000 and 10,000 and then this carrier frequency, and you can adjust all of it and have a bigger, lower, whatever, to be Russian. Not the... How did Russia get its name? The Russian name. Almost there. Nope. Do we need it? No. It is named for the country. Absolutely named for the country. Because the Russians are under a war. Yeah, it's not that hard. War is just now. This was created by the Russian Olympic medical team to try to find a way to strengthen their athletes faster, bigger, better, stronger. Very competitive. Yeah. So it was for Olympics. So as the Russians developing this... Back, I want to say like the 60s, right? It's been around for quite some time. So it was a way to try to become stronger. What we have realized over... Yeah, Russian-designed practice of the quad. It was literally just the quad, trying to get stronger faster. It was like try to jump higher, run faster, lift more. Like it was summer Olympics kind of thing, right? Yeah. Yeah, right? Well, not back then. But they were trying to do it to strengthen healthy muscle to get stronger. What we have realized through research is that doesn't really work. We can't strengthen healthy tissues, healthy muscle to get stronger using this. But we absolutely can strengthen weak or deactivated muscles. Muscles that have been immobilized. Flaccid muscles, because of something, not flaccid because of nerve, right? It still has to be innervated. But we can reacclimate, retrain weakened or degenerated muscles to be stronger. We can get back towards that normal, but we're not going to go normal to above normal. So it didn't really work for the Olympic team. But it was great for healthcare. So thank you, Russia. Maybe USSR back then. I don't know. But we can use it on any muscle. But the only thing that's changeable with Russian is the amplitude, your intensity, right? And the duty cycle. How much on offer are you using? Everything else that's up here has to stay the same. If you don't, then it becomes pulsed by phasic. So Russian is a medium frequency altering current at 2500 hertz. Absolutely 2500 hertz. You have, it's pulsed, right? So you have a 10 millisecond burst followed by equal 10 millisecond rest. But again, that's milliseconds, hundreds of a second. So this is below sensory threshold. But what it isn't is below nerve stimulation threshold. So it's stimulating and relaxing that nerve to create a nice amount of muscle activation. And then you have 50 bursts per second. So you said amplitude and what was the other thing that we could change? Duty cycle. The duty cycle is what the patient is going to feel. That's the work-rest cycle. So for you guys, when you were doing that, your duty cycle was 5 to 5 or 10 to 10, right? When you were having a contract for 10 seconds, relax for 5 seconds. If you had it set to Russian, inside that 5 second contraction, you had 10 millisecond bursts, 50 bursts per second. And 2500 hertz. Would this be common for like after like ACL injuries, you like weighting that quad muscle back? Because the faster we get that quad muscle, the faster they can start walking with an unlocked brace. And the faster they can walk with an unlocked brace, the faster they get into a normal gait cycle, the less likely they are to have a hip or knee or back injury, right? We can start to progress them as soon as we get that good quad control. But if we can't get quad control, we can't do any of that. So yeah, we can throw out some Russian, have it activate first, have them start to work with it. So it's squeezing, they're lifting, everything's happening together, and then eventually we can start turning that Russian off and they just maintain their quad control. I'm saying eventually, probably not on the first treatment, but eventually, right? After a couple treatments. But it's a way to get that muscle to remember how to contract together. Because we can have them do like a quad set with it. To be Russian. So if you change it from 2500 hertz to 3000 hertz, but to keep everything else the same. 10 milliseconds on off, 50 burs per second, everything else stays the same, but now it's 3000 hertz. Now you're in post biphasic. Russian is post biphasic. It's just a very specific setting of post biphasic. Yep. To be Russian, they have to be that. But to get a muscle contraction, you don't have to do that. You can easily do post biphasic. If you're crying out loud, you can do pre-mod and get muscle contraction, right? I mean, there's a lot of ways to get muscle contraction. But to be Russian, do you giggle every time I say that? Every time I say to be Russian, she goes... So that has to stay constant to be Russian. One change, you make it 11 millisecond bursts. Now it's post biphasic. No, let me just say, you can't change that. So even on the 10 new years, you can't change the millisecond bursts. And I don't even believe you can change the burst per second. But then you see that you get that on-off burst in there, but that is sub-threshold. I want you to...that's sub-sensory threshold. You're not feeling that 10 millisecond burst. Questions on Russian? Okay, monophasic is literally what it sounds like. One phase. So what does that look like? What kind of current is that? That's a DC current, right? There's no plus and minus. It's all plus, plus, plus. So this is how when you are setting somebody up, most of the units don't say DC. They'll say monophasic. One phase. And you will choose a positive or negative over your site depending on what it is you're going for. And that's why the ends of the cords have that little red and black tip on the chitinugas. It's going to be the same as a positive, negative anacathode that we saw on the ion tip. So this is how you would get to that DC current and say a chitinuga. I think chitinuga is the only one that does monophasic that we have. So you're not going to see that on the rich mar, or I don't think it's on the rich mar. I don't think it's on the combo here. But usually we're using that, in this case, we're using it for tissue healing or for swelling or something. The idea is that we're trying to