Additional Therapeutic Uses of ES

8/2/2019 Additional Therapeutic Uses of ES

1/12

2011/12/9

1

() Lecture8:

AdditionalTherapeuticUsesofElectricity

100 1

AdditionalTherapeuticUsesof

Electricity

Woundmanagement

Osteogenesis

Edemareduction

Peripheralcirculation

Incontinence

2

ESforWoundManagement

Wound abreakinthecontinuityofsofttissuecausedbyphysical,

chemicalorbiologicalinsult

Complications:chronicinflammation,infection,andscarring

associatedwithotherimpairments,suchaspain,decreasedmobilityandmotorfunction

ES asdirectintervention,oradjunctstootherwound

management

PatientsreferredtoPTforEStreatmentareusually: Chronicwoundnotresponsivetoothertreatment:Neuropathic

ulcer,pressureulcer

Orneedtoacceleratehealingprocess

3

PhasesofWoundHealing Phase1

Inflammatoryphase(day1 6)

Initialvascularconstriction:decreaselocalblood

flow,allowmoreefficientclotting

Vasodilation:deliverchemicals,cells,nutrientsandoxygentoinjuredtissue

Promotecapillarypermeability

Chemotaxis:bodilycells,bacteria,andothersinglecell

ormulticellularorganismsdirecttheirmovements

accordingtocertainchemicalsintheenvironment

Increasefibroblastandmacrophageactivity

4


2/12

2011/12/9

2


Proliferativephase(day3 20)

Reepithelialization:regrowskinoverthewound

Toprovideaprotectivebarriertopreventfluidandelectrolytelossandtodecreasetheriskofinfection

Fibroblastsarriveandbegintoproducecollagentorebuildthesiteofinjury

Neovascularization Developmentofanewbloodsupplytotheinjuredarea

Newvesselsareneededtosupplyoxygenandnutrientstotheinjuredandhealingtissue

5


Remodelingphase(day9on)

Maturationphase

Continuedfibroblasticandcollagenactivity

Collagenundergoesbothsynthesisandlysis

balancebetweenthesetwoprocessesdetermines

theeventualamountofscarformation

Thisphaseischaracterizedbyscarcontractionand

mayalsoincludescarhypertrophy

6

RationalesForUsingESForWound

Management

Skinbattery&currentofinjury

Galvanotaxis

Speeduphealingprocess

Antimicrobialeffect

7

SkinBattery

Transepithelial potentialbetweenthedermisandepidermis

Whentheskinisdamaged,thedifferenceinpotentialisbelievedtobethesourceofthecurrentofinjury

Thiscurrentisatriggertowoundhealingandalsoassociateswiththemoistwoundhealingprocess

Ifwoundsarepermittedtodry

ceasethecurrentofinjury UseEStoinfluencethecurrentofinjuryandthelateralelectricfield

thatexistsinareasofskindisruption

8


3/12

2011/12/9

3

Galvanotaxis Cellwithchargeattractedtoanelectricfield

9

SpeedUpHealingProcess Augmentationofcollagensynthesisandproliferationof

fibroblasts Fibroblastsnormallymigrateintothehealingwound,especially

duringtheproliferativephase

ESincreasesDNAsynthesisandcollagensynthesis

Promoteangiogenesisandwoundmicroperfusion EScouldstimulatecapillaryregrowthintothewound

Enhancedmicrocirculation inchronicwoundinresponsetoES

Enhancingtherateofepithelialization Fasterepithelialization

Evidenceshowedthatifwoundstreatedwithanode7days,orwithcathodeonthefirstdayandanodefortheremaining6days

Enhancingbloodflowtowounds Enhancingbloodflowtowoundsbytheuseofelectrical

stimulationappliednearthewound10

Antimicrobialeffect

Electricalstimulationhasbacteriostatic(inhibitgrowth)orbactericidal(killbacteria)effectsonvariouspathogenicorganismsthatarecommonlyfoundtoinfectwounds

Electrodepolarityforantimicrobialeffects CathodeforPseudomonasaeruginosa ()

BothanodeandcathodeforStaphylococcusaureus()

Electrodecompositionforantimicrobialeffects Electrodesconsistingofsilverwireshowedsuperior

effectswhencomparedwithstainlesssteel,platinum,orgoldwireelectrodes

11

ESForWoundManagement

Cleansewoundthoroughly,removedead

tissuesandpetrolatumproducts

Cover/fillwoundspacewithgauzepads

soakedinsalineorhydrogel

Placeanelectrodeonthegauzepacking,cover

withdrygauze,holditwithbandagetape

Dispersiveelectrodeusuallyproximaltothe

wound

12Source:Woundcareinformationnetwork,SUSSMANPHYSICALTHERAPYINC.


4/12

2011/12/9

4

Microcurrent ES Polarity&electrochemicalreaction

Cathode(negative):raisethepHtoalkalinityformingmaybeusedforitsbactericidaleffectorasanadjuncttodebridementbecauseofitssclerolytic ability(decreaseproteindensity)tosolubilizethrombiandnecrotictissue

Anode(positive):lowerthepHtoacidityformingmaybeusedforitseffectofsclerosing tissueandcoagulatingbloodleakingfromsmallvesselsmayalsoaugmentclosureofthewoundbyproducingacongealedscar

Ifinfectionwithorganisms,suchasEcoliandPseudomonas

aeruginosa (

)ispresent,thenegativeelectrodeshouldbeleftinthewoundareauntilthesignsofinfectionarenotevident.Thenegativeelectroderemainsinthewoundfor3daysaftertheinfectionclears.

IfthewoundisinfectedwithbacteriasuchasStaphylococcusaureus (),thepositivepolemaybeamoreappropriatechoice

13

Microcurrent ESApplication Thenegativeelectrodeispositionedinthewoundareafor

thefirst3days;after3daysthepolarityisreversed

Ifthewoundsizestopsdecreasing,thenreturnthenegativeelectrodetothewoundareafor3days

Ingeneral,thesecondelectrodeisapproximatelythesamesizeastheactiveelectrodeandisplacedat15to30cmawayfromthewound

14

RecommendedProtocol

Currentintensity


5/12

2011/12/9

5

PolarityConsideration&Protocol Selectionofpolarity

Usuallyinitiatedwiththecathodeastheactiveelectrode

Afterseveraldaysoftreatmenttheelectrodepolarityisreversedtothepositivecharge

Negativepolarityisusedifmicroorganismsarepresentcontinuetousenegativepolarityuntilthewoundisculturefreefor3days

Positivepolarityisusedifthewoundisculturefreeoris

usedafterthewoundisculturefreefor3days Recommendedprotocol

Frequency:30 130pps

Amplitude:subthresholdtomusclecontraction

17

ESForWoundHealing HighVoltage

PulseCurrent

18

ESForWoundHealing HighVoltage

PulseCurrent Signsofadverseeffects

Skinirritationortinglingundertheelectrodes

Pain

Precautions Transcerebralstimulation

Stimulationovertheeyes Youngchildrenunderage3years

Contraindications

Presenceofmalignancy

Activeosteomyelitis

Topicalsubstancescontainingmetalions:povidoneiodine,zinc,silversulfadiazine,mercurochrome

Electronicimplants

19

ESForOsteogenesis

10%ofthe7.9millionannualfracturepatientsintheUnited

Statesexperiencenonunionand/ordelayedunions

Severalmethodshavebeenusedtopromotebonehealing Electricalstimulation

Lowintensitypulsedultrasound

Electromagneticstimulation


6/12

2011/12/9

6

StagesofBoneHealing Inflammatorystage

Repairstage

Remodelingstage

21

Hematoma

Cartilaginous

callus Bonycallus Remodeling

1.Inflammatorystage Hematomaformswithinthefracturesite(first

fewhourstodays)

Cleanupdeadtissues

Callusformation

Thisstagelasts2 4weeks,overlapswiththe

nextstage

22

2.Repairstage

Cartilaginouscallus

Painandswellingsubsideasthebonyfragmentsunitedby

cartilaginoustissue

Osteoclastsremovedeadbonefragments

Hardcallus Cartilagehardening fromeachendoffracturetowardthecenter

Thisstagelasts1 2months

23

3.Remodelingstage

Weak strongbonmaterial

Bonereturnstoitsoriginalshapeand

structure

Remodelingoftheboneoccursslowlyover

monthstoyearsandishelpedbymechanical

stress(i.e.weightbearing).

24


7/12

2011/12/9

7

RationaleForUsingESFor

Osteogenesis Chemicalgradientswithinthebone

arethesourceofbioelectricpotentials

Normalbonehaspiezoelectricproperties Highercellularactivity(epiphysial

platearea) morenegative

Bonegenerateselectricalpotentialsinresponsetomechanicalstress Compression Negative

Tension Positive

Thepolaritychangesafterdiaphysisfracture

EScausesionicmigration

25

Microcurrent ES Polarityofstimulation

Anegativeelectrodewasplacedclosetobutdistaltothefracturesite

Apositiveelectrodewasplacedproximaltotheimmobilizingdevice

Recommendedprotocol Currentintensity:justperceptibletothepatient

Pulseduration:ContinuousorpulsedDCwithlongest

durationallowedontheunit(100 200msec) Frequency:lowestfrequencyallowedontheunit(5 10

pps)

Treatmentduration:30minutes 1hour

Treatmentfrequency:3 4timesperday

26

TENS

Ifthefracturesiteisenclosedinaplastercast,electrodes

shouldbeplacedproximalanddistaltothecast,2or4

electrodesareused

27

TENSApplication Ifthefracturesiteisfreeof

casting,3basicpatternsare

available

With2electrodes,oneplacedon

eithersideofthefracturesite,

about6inches(15cm)apart

28


8/12

2011/12/9

8

TENSApplication With4electrodes,across

pattern,about6inchesapart,

withthecrossingpointdirectly

overthefracturesite

29

TENSApplication Ifthefracturesiteisfreeof

casting.With2electrodes,a

sandwichpattern,withthe

fracturesitebetweenthetwo

electrodes

30

TENS

Recommendedprotocol Frequency:thehighest

frequencyavailableonunit(120Hz)

Pulsedwidth:thewidestwidth(300 s)

Intensity:thelowestpossible,barelysensedbypatient

Treatmentduration:1hour/session

Treatmentfrequency:4times/day

Sideeffects Analgesiawasreportedby

patientswhocomplainedofpain

asasymptomofthenonunion

31

ESForEdemaReduction

Rationale

Polaritymovesnegativelychargessubstancethatcausededema

Sensorylevelstimulation Polarityofelectrode

Tousethepolarityofanelectricalstimulustorepelsimilaritychargedsubstancesfromtheedematousarea

Becausebloodcellsandplasmaproteinscarryanegativecharge anegativeelectrodeplacedoveranedematousareamayrepelthesenegativelychargedsubstancesfromtheareaofstimulation decreasingtheamountofedemathroughafluidshift

32


9/12

2011/12/9

9

ESForEdemaReduction Rationale 1

Sensorylevelectrical stimulustorepelsimilarity

chargedsubstancesfromtheedematousarea

Bloodcellsandplasmaproteinscarryanegativecharge

anegativeelectrodeplacedoveranedematousarea

mayrepelthesenegativelychargedsubstancesfrom

theareaofstimulation decreasingtheamountof

edemathroughafluidshift

33

Rationale 2 Microcurrent stimulationofthelocal

neurovascularcomponents

Amicroamp stimulationmaycausea

vasoconstrictionandreducethepermeabilityof

thecapillarywallstolimitthemigrationofplasma

proteinsintotheinterstitialspaces

Thiswouldretardtheaccumulationofplasma

proteinsandtheassociatedfluiddynamicsofthe

edemaexudate

34

Rationale 3

Motorlevelstimulation

Electricallyinducedmusclecontractioncan

effectivelyleadtoareductioninedemaby

mobilizingtheedematomovefromtheinterstitialcompartmenttothebloodvascularsystemand

lymphaticsystem

35

ESForEdemaReduction HVPC

Applicationtechnique

Waterimmersionelectrodetechniqueismore

effectivethanusingsurfaceelectrodes

Polarityofstimulation Activeelectrodesisnegative

36


10/12

2011/12/9

10

HVPCRecommendedProtocol Sensorylevelstimulation

Intensity:10%lessthanneededtoproduceavisiblemusclecontraction

Frequency:high(120pps)

Timeoftreatmentafterinjury:beginimmediatelyafterinjury

Treatmentduration:30minutesevery4hours

Motorlevelstimulation Intensity:strong,comfortablemusclecontractions

Frequency:35 50pps

Ontime:5 10sec;Offtime:5 10sec

Theparttobetreatedshouldbeelevated

AROMmaybeencouragedatthesametimeifitisnotcontraindicated

Treatmentduration:20 30minutes

Treatmentfrequency:2 5timesperday

37

ESForPeripheralCirculation Introduction

Mostcommonlyappliedtopreventpostoperative thromboemboliccomplicationsandtoimprovecirculation

Factorscontributingtotheformationofathrombosis Changesinbloodflow

Changesinbloodcoagulability

Changesinthevesselwall

RationaleforusingES Electricalstimulationofthecalfmusclespreventedadecrease

intherateofvenousbloodflowinthelegsduringsurgeryandthereforedecreasedthefrequencyofdeepvenousthrombosis

Increasedcapillarybloodflowinthestimulatedmusclesresultsfromacombinationofreflexivevasodilationandanincreaseincapillarygrowthduringlongtermelectricalstimulation

38

ESForPeripheralCirculation

InterferentialcurrentorRussianstimulation Electrodeplacement:Oversensorynerves

Recommendedprotocol Currentintensity:maximumtoleratedtingling(sensorylevelstimulation)

Frequency:50 200bps

Cycleduration:20 100 s

Dutycycle:50%ifRussianstimulation Treatmentduration:20 60minutes

Lowfrequencystimulators Electrodeplacement:Overmotornervesofinnervatedmuscles

Recommendedprotocol Waveform:balancedasymmetricalbiphasicpulsedcurrent

Currentintensity:motorresponse

Frequency:30 100pps


39

ESForIncontinence Indications(1)

Stressurinaryincontinence

Involuntarylossofurinewhentheintravesical (withinbladder)pressureexceedsthemaximumurethralclosurepressureintheabsenceofdetrusoractivity

Smallamountsofurinearelostconcurrentwiththeincreasedintraabdominalpressure

Urgeurinaryincontinence Involuntarylossofurineassociatedwithanuninhibiteddetrusor

contractionthatoverwhelmsthesphinctermechanism

Mixedurinaryincontinence

Urinaryfrequencyorhesitancywithpelvicfloordyssynergia

40


11/12

2011/12/9

11

ESForIncontinence Indications(2)

Fecalincontinencerelatedtopelvicfloorweakness

Levator syndrome Painintheregionofthecoccyx

Painfulspasmsofthemusclesaroundtheanuswithoutknowncause

Althoughbowelmovementsmatnotbepainful,

patientsoftenreportdisturbedbowelfunction,constipation,orfrequency

Interstitialcystitis Aconditionofoversensitivityofthebladder

41

ClinicalApplication Purpose

Tohelpthepatientidentifythepelvicfloormuscle

location,provideproprioception,andassistthe

contraction

Toachieveautonomicdampeningofthesebladder

contractionsbyaugmentingsympathetic

dominance

Electrodeselection:Whenpossible,an

internalelectrodeispreferred

42

RecommendedProtocols

Vaginal andanalplugstimulation:aanalorvaginalplugwithtwoembeddedringelectrodes

Patientsposition:beginwiththepatientinanantigravityposition(ie,relaxedhooklyingorsidelyingwithoneortwopillowsunderthepelvisorbetweenthelegs)andslowlyprogresstostanding

Themostcomfortablecurrentsaredeliveredbycircularelectrodes,whichareabletodispersecurrentoverlargesurfaceareas

Frequency:5 50Hz Ahigherfrequencyof50Hzismostamenabletoinnervatedmuscle it

workswelltoteachmusclecontraction,proprioception,andawareness

Alowerfrequencyof5 20Hzismostamenabletotreatdetrusorinstabilityandurgency

Treatmentdurationandfrequency:2or3minutesofstimulation1 3timesadayisagoodbeginning,graduallybuildingupto15minutes1 2timesaday

Afterthefirstfewsessions,whenpatienthasbeenabletoidentifythecontraction, askthepatienttocontractwiththecurrent,relaxinginbetween

43

InterferentialCurrent

Pelvicfloorstimulation

Electrode:externalelectrodes

Patientsposition:asemireclined positionwiththehipsandkneesflexedandsupported

Electrodeplacement:bipolartechnique Female:oneelectrodewasplacedunderischial tuberositywitha

secondelectrodeovertheanteriorperineum,immediatelyinferiortothesymphysis pubis

Male:electrodesplacedoneachsideoftheglutealcleft,justanteriortotheanus

Currentintensity:50 80mA,maximumlimitofpatientcomfort

Frequency:asweepfrequencyof10 50Hzorafixedfrequencyof50Hz

Treatmentduration:30minutes

44


12/12

2011/12/9

12

TENS Purpose:

Tobemoreeffectiveinrelievingpelvicandperineal pain

Tobeusefulintreatingdetrusorinstability

Electrodeplacement:Relatedacupuncturepointsareuseful Spleen6(Sp 6):3cmdirectlyabovethetipofthemedial

malleolusontheposteriorborderofthetibia

Spleen10(Sp 10):withkneeflexed,2cmabovethesuperiormedialborderofthepatellaonthebulgeofthemedialportion

ofquadricepsfemoris Largeintestine4(LI4):inthemiddleofthe2ndmetacarpal

boneontheradialside

Acrossedfashionoverthelowerabdomenorlumbarsacralareas

45

TENSParameters Mode:conventionalsetting

Currentintensity:sensorylevel

Frequency:60 100Hz

Pulsedduration:100 150 s


Treatmentfrequency:1 5timesaday

46

Documents

Additional Therapeutic Uses of ES