Ch13.Stimulators.fmt

© 2005 – FA Davis© 2005 – FA Davis

Electrical StimulationElectrical Stimulation

Clinical ApplicationClinical Application


High Volt Pulsed High Volt Pulsed StimulationStimulation

ParametersParameters

Amplitude:Amplitude:0 to 500 mA0 to 500 mA

VoltageVoltage::0 to 500V0 to 500V

Pulse Frequency: Pulse Frequency: 1 to 120 pps1 to 120 pps

Pulse Duration:Pulse Duration:13 to 100 13 to 100 µµsec sec

Phase DurationPhase Duration::20 to 45 20 to 45 µµsec sec

Adjustable ParametersAdjustable Parameters Duty cycleDuty cycle Electrode alternating rateElectrode alternating rate Electrode balanceElectrode balance IntensityIntensity PolarityPolarity Probe electrodeProbe electrode Surge/Ramp Surge/Ramp

Current: Monophasic

TheoryTheory

Short-duration, high amplitude (voltage) pulses Short-duration, high amplitude (voltage) pulses can produce comfortable, moderate can produce comfortable, moderate contractions.contractions. Short phase duration targets sensory nerves and Short phase duration targets sensory nerves and

motor nervesmotor nerves Wave form is modified to decrease total current to Wave form is modified to decrease total current to

improve comfortimprove comfort Each electrode has a known polarityEach electrode has a known polarity

May cause galvanic (ion) changesMay cause galvanic (ion) changes Short phase duration and long interpulse interval Short phase duration and long interpulse interval

probably negates any effectprobably negates any effect

UsesUses

Reeducation of Reeducation of peripheral nervesperipheral nerves

Delay denervation and Delay denervation and disuse atrophy by disuse atrophy by stimulating muscle stimulating muscle contractionscontractions

Reduction of post-Reduction of post-traumatic edematraumatic edema

Increase in local blood Increase in local blood circulation circulation (unsubstantiated) (unsubstantiated)

Restoring range of Restoring range of motion:motion:

Reduction of muscle Reduction of muscle spasmspasm

Inhibition of spasticityInhibition of spasticity Reeducation of partially Reeducation of partially

denervated muscledenervated muscle Facilitation of voluntary Facilitation of voluntary

motor function motor function

EffectsEffects

Neuromuscular StimulationNeuromuscular Stimulation Moderate to strong muscle contractionsModerate to strong muscle contractions Less torque production than NMESLess torque production than NMES

Pain ControlPain Control Sensory-level (short-term)Sensory-level (short-term) Motor-levelMotor-level Acute pain: Positive electrode over painful siteAcute pain: Positive electrode over painful site Chronic pain: Negative electrode over siteChronic pain: Negative electrode over site

EffectsEffects

Edema ControlEdema Control Negative electrode Negative electrode maymay prevent the prevent the

formation of edemaformation of edema Causes the gaps between endothelial cells Causes the gaps between endothelial cells

to close, preventing leakageto close, preventing leakage

Edema ReductionEdema Reduction Motor-level stimulation “milks” the venous Motor-level stimulation “milks” the venous

and lymphatic vessels.and lymphatic vessels.

EffectsEffects

Blood FlowBlood Flow Associated with frequency and intensity of Associated with frequency and intensity of

muscle contractionmuscle contraction Wound HealingWound Healing

Electrode polarity kills or repels different Electrode polarity kills or repels different microbesmicrobes

Assists healing and inhibits bacteria growthAssists healing and inhibits bacteria growth Direct current techniques are more effective Direct current techniques are more effective

than HVPSthan HVPS

Notes and PrecautionsNotes and Precautions

Motor-level stimulation can cause unwanted Motor-level stimulation can cause unwanted tension on the muscle fibers, the tendons, or tension on the muscle fibers, the tendons, or the bony insertion.the bony insertion.

Muscle fatigue can occur if the duty cycle is too Muscle fatigue can occur if the duty cycle is too high.high.

Intense or prolonged stimulation may result in Intense or prolonged stimulation may result in muscle spasm and/or muscle soreness.muscle spasm and/or muscle soreness.

Improper use can cause electrode burns or Improper use can cause electrode burns or irritation.irritation.


Transcutaneous Transcutaneous Electrical Nerve Electrical Nerve StimulationStimulation


Total current flowTotal current flow0 to 100 mA0 to 100 mA

Pulse frequencyPulse frequency1 to 150 pps1 to 150 pps

Pulse durationPulse duration10 to 500 10 to 500 µµsec sec

Phase durationPhase duration5 to 250 5 to 250 µµsec sec

Adjustable ParametersAdjustable Parameters IntensityIntensity Mode (output Mode (output

modulation)modulation) Pulse durationPulse duration Pulse frequency Pulse frequency

Current: Biphasic

TheoryTheory

Adjustable phase durations specifically Adjustable phase durations specifically target sensory, motor, and pain fiberstarget sensory, motor, and pain fibers

Phase duration is matched with pulse Phase duration is matched with pulse frequency to produce specific effectsfrequency to produce specific effects

Biphasic form prevents net residual Biphasic form prevents net residual chargecharge

UsesUses

Control of acute or chronic painControl of acute or chronic pain Management of postsurgical painManagement of postsurgical pain Reduction of post-traumatic acute pain Reduction of post-traumatic acute pain

EffectsEffects

High – Frequency TENS (Sensory Level)High – Frequency TENS (Sensory Level) Short phase duration (< 100 Short phase duration (< 100 µsec)µsec) High pulse frequency (60 to 100+ pps)High pulse frequency (60 to 100+ pps) Sensory-level outputSensory-level output Activates spinal gateActivates spinal gate Long-term treatmentLong-term treatment

Output must be modulated to reduce Output must be modulated to reduce accommodationaccommodation

EffectsEffects

Low – Frequency TENS (Motor level)Low – Frequency TENS (Motor level) Long phase duration (150 to 250 Long phase duration (150 to 250 µsec)µsec) Low pulse frequency (2 to 4 pps)Low pulse frequency (2 to 4 pps) Motor-level outputMotor-level output Pituitary gland releases:Pituitary gland releases:

ACTHACTH ββ-lipotropin-lipotropin

Causes the release of Causes the release of ββ-endorphin-endorphin Binds to the A-beta and C fiber receptor sitesBinds to the A-beta and C fiber receptor sites Blocks the transmission of painBlocks the transmission of pain

EffectsEffects

Brief – Intense TENS (Noxious level)Brief – Intense TENS (Noxious level) Long phase duration (300 to 1,000 Long phase duration (300 to 1,000 µsec)µsec) High pulse frequency (> 100 pps)High pulse frequency (> 100 pps) Noxious-level outputNoxious-level output

Very short treatment durationVery short treatment duration

Creates a negative feedback loop in the CNSCreates a negative feedback loop in the CNS Theoretically “short circuits” the pain carrying loopTheoretically “short circuits” the pain carrying loop Opiates inhibit the release of Substance POpiates inhibit the release of Substance P

Blocks or reduces pain transmissionBlocks or reduces pain transmission


Do not use to treat pain of unknown originDo not use to treat pain of unknown origin TENS is a symptomatic treatmentTENS is a symptomatic treatment Improper use can result in electrode burns or Improper use can result in electrode burns or

skin irritation.skin irritation. Intense or prolonged stimulation may result in Intense or prolonged stimulation may result in

muscle spasm and/or muscle soreness.muscle spasm and/or muscle soreness. Intake of 200 mg or more of caffeine may Intake of 200 mg or more of caffeine may

reduce the effectiveness of TENSreduce the effectiveness of TENS Narcotics decrease the effectiveness of TENSNarcotics decrease the effectiveness of TENS


Interferrential Interferrential StimulationStimulation


CurrentCurrent: : 1 to 100 mA1 to 100 mACurrent flow (RMS)Current flow (RMS) 0 to 50 mA0 to 50 mAVoltageVoltage:: 0 to 200 V0 to 200 VCarrier FrequencyCarrier Frequency: :

Fixed at 2500 to 5000 HzFixed at 2500 to 5000 HzBeat FrequencyBeat Frequency: : 0 to 299 Hz0 to 299 HzSweep FrequencySweep Frequency: : 10 to 500 µsec 10 to 500 µsec

Adjustable ParametersAdjustable Parameters IntensityIntensity Beat frequency – Analogous to the Beat frequency – Analogous to the

number of cycles or pulses per number of cycles or pulses per secondsecond

Burst duty cycle – Bursts separated Burst duty cycle – Bursts separated by periods of no stimulation by periods of no stimulation (interburst interval)(interburst interval)

Interburst interval – Duration of time Interburst interval – Duration of time between burstsbetween bursts

Premodulation (e.g., Russian Premodulation (e.g., Russian Stimulation)Stimulation)

RampRamp Sweep – Variation in the beat Sweep – Variation in the beat

frequency; Set with a low value and a frequency; Set with a low value and a high valuehigh value

Vector/Scan – Variation in current Vector/Scan – Variation in current intensity intensity

Current: Alternating

Two alternating currents form a single interference current. Premodulated output is based on a single alternating current.

TheoryTheory

High-frequency waves easily overcome High-frequency waves easily overcome skin resistanceskin resistance

The two waves are slightly out of The two waves are slightly out of frequencyfrequency

They cancel each other out and produce They cancel each other out and produce a frequency of 1 to 299 Hz in the tissuesa frequency of 1 to 299 Hz in the tissues

Results in a comfortable stimulation Results in a comfortable stimulation capable of depolarizing sensory and capable of depolarizing sensory and motor nervesmotor nerves

Carrier Wave

=

Variable Wave

Interference Wave

UsesUses

Acute painAcute pain Chronic painChronic pain Muscle spasm Muscle spasm

EffectsEffects

Pain ControlPain Control Similar to TENSSimilar to TENS Most frequently used for motor-level pain Most frequently used for motor-level pain

controlcontrol

Muscle ContractionsMuscle Contractions Neuromuscular re-educationNeuromuscular re-education Edema reductionEdema reduction


Do not use in the presence of unknown Do not use in the presence of unknown pain or pain of central originpain or pain of central origin

Can cause electrode burns, skin irritationCan cause electrode burns, skin irritation Motor-level use can cause muscle spasm Motor-level use can cause muscle spasm

or muscle sorenessor muscle soreness


Neuromuscular Neuromuscular Electrical StimulationElectrical Stimulation


Total current:Total current:0 to 200 mA0 to 200 mA

Pulse frequency:Pulse frequency:1 to 200 pps1 to 200 pps

Phase duration:Phase duration:20 to 300 20 to 300 µµsecsec

Intrapulse interval:Intrapulse interval:Appx. 100 Appx. 100 µµsecsec

Adjustable ParametersAdjustable Parameters IntensityIntensity Pulses per secondPulses per second Duty cycleDuty cycle Reciprocal rateReciprocal rate Ramp Ramp

Current: Biphasic, Premodulated

TheoryTheory

Current type varies by manufacturerCurrent type varies by manufacturer Tends to have long phase durationTends to have long phase duration Biphasic and alternating current Biphasic and alternating current

decreases possibility of electrode decreases possibility of electrode irritationirritation

UsesUses

Maintaining range of motionMaintaining range of motion Muscle reeducationMuscle reeducation Prevention of joint contracturesPrevention of joint contractures Prevention of disuse atrophyPrevention of disuse atrophy Increasing local blood flowIncreasing local blood flow Decreasing muscle spasm Decreasing muscle spasm

EffectsEffects

Can produce substantial muscular Can produce substantial muscular tensiontension

Capable of increasing strengthCapable of increasing strength Used when limb is immobilizedUsed when limb is immobilized Also slows the onset of atrophyAlso slows the onset of atrophy

Duty cycle is required to prevent fatigueDuty cycle is required to prevent fatigue


Improper use may result in electrode burns or Improper use may result in electrode burns or skin irritationskin irritation

Intense or prolonged stimulation may result in Intense or prolonged stimulation may result in muscle spasm and/or muscle soreness.muscle spasm and/or muscle soreness.

An electrically induced contraction can An electrically induced contraction can generate too much tension within the musclegenerate too much tension within the muscle

Use caution:Use caution: Musculotendinous lesions, the tension from the Musculotendinous lesions, the tension from the

contraction may injure the muscle or tendon fiberscontraction may injure the muscle or tendon fibers Cases where the muscle’s bony attachment is not Cases where the muscle’s bony attachment is not

securesecure


IontophoresisIontophoresis


Total current:Total current:Up to 5 mAUp to 5 mA

Voltage:Voltage:80 V80 V

DosageDosage: : 0 to 80 mA/min 0 to 80 mA/min

Adjustable ParametersAdjustable Parameters:: Dosage:Dosage:

AmperageAmperage DurationDuration

PolarityPolarity

Current: Direct

TheoryTheory

The charges associated with a DC can “drive” The charges associated with a DC can “drive” medications into the tissuemedications into the tissue

Medication must have an electrical chargeMedication must have an electrical charge Negative charges driven from the cathodeNegative charges driven from the cathode

Attracted towards the anodeAttracted towards the anode And vice-versaAnd vice-versa

Requires specialized electrodes to hold the Requires specialized electrodes to hold the medicationmedication

Dose-Oriented TreatmentsDose-Oriented Treatments

Medications are Medications are delivered in mA/Mindelivered in mA/Min Milliamp MinutesMilliamp Minutes

Function of the amount Function of the amount of current times the of current times the duration of the duration of the treatment:treatment: 5 mA applied for 20 5 mA applied for 20

minutesminutes 5mA * 20 min = 100 5mA * 20 min = 100

mA/MinmA/Min 4 mA applied for 25 4 mA applied for 25

minutesminutes 4mA * 25 minutes = 100 4mA * 25 minutes = 100

mA/MinmA/Min

Dose-oriented treatments provide the basis for the Ionotopatch™ which delivers the medication using a low current applied for an extended time.

UsesUses

Delivers medication to the tissues Delivers medication to the tissues to treat:to treat: Acute inflammationAcute inflammation Chronic inflammationChronic inflammation ArthritisArthritis Myositis ossificansMyositis ossificans Myofascial pain syndromesMyofascial pain syndromes Delivering local anesthetics before Delivering local anesthetics before

injection or other minor invasive injection or other minor invasive proceduresprocedures

Hyperhidrosis Hyperhidrosis

Sample MedicationsSample MedicationsMedication Pathology Concentration Dosage Polarity

Acetic acid Myositis ossificans 2% 80 mA/Min Negative

Dexamethason Inflammation 4mg Decadron 41 mA/Min Negative and lidocaine Pain control 4% Xylocaine 40 mA/Min Positive

Lidocaine and Pain control 4% Lidocaine 30 mA/Min Positive epinephrine 0.01 mL/1:50,000 30 mA/Min Positive

Dexamethasone Inflammation 2cc 4mg/mL 41 mA/Min Negative

Refer to the prescription for the exact treatment parameters.Each electrode size has a maximum treatment amperage. Consult the packaginginformation included with the electrodes.


Controlled medications require a physician’s Controlled medications require a physician’s prescription: prescription: Each patient requires his/her own prescriptionEach patient requires his/her own prescription Follow any notes or instructions provided by the pharmacist. Follow any notes or instructions provided by the pharmacist. State practice acts may further regulate the delivery of State practice acts may further regulate the delivery of

iontophoresis.iontophoresis. The exact medication dosage delivered is unknown.The exact medication dosage delivered is unknown. Erythema under the electrodes is commonErythema under the electrodes is common Too intense of a treatment dose can result in electrode Too intense of a treatment dose can result in electrode

burnsburns Do not reuse electrodesDo not reuse electrodes

Medications remain, contaminating the electrode Medications remain, contaminating the electrode


MicrocurrentMicrocurrent


Total current flow:Total current flow:1 to 999 1 to 999 µµA (Peak current)A (Peak current)25 to 600 25 to 600 µµA (RMS)A (RMS)

Pulse frequency:Pulse frequency:0.1 to 1000 Hz 0.1 to 1000 Hz

Pulse duration:Pulse duration:0.5 to 5000 0.5 to 5000 µµsecsec

Phase durationPhase duration::0.5 to 5000 0.5 to 5000 µµsec sec

Adjustable ParametersAdjustable Parameters:: IntensityIntensity Polarity/alternating Polarity/alternating

polarity polarity

RampRamp Threshold – Ohm Meter Threshold – Ohm Meter

Current:Monophasic. (Polarity reverses)

TheoryTheory

Small, subsensory pulses can affect the Small, subsensory pulses can affect the function of healing tissuesfunction of healing tissues

Injured tissues have a reversal of their normal Injured tissues have a reversal of their normal electrical charges (“injury potential”)electrical charges (“injury potential”)

MET attempts to normalize the electrical MET attempts to normalize the electrical potentialpotential

Activation of ATP and increased ATP levelsActivation of ATP and increased ATP levels The efficacy of MET has not been The efficacy of MET has not been

substantiated.substantiated.

Uses*Uses*

Acute and chronic Acute and chronic painpain

Acute and chronic Acute and chronic inflammationinflammation

Reduction of edemaReduction of edema SprainsSprains StrainsStrains Contusions Contusions

Temporomandibular Temporomandibular joint dysfunctionjoint dysfunction

Carpal tunnel Carpal tunnel syndromesyndrome

Superficial wound Superficial wound healinghealing

Scar tissueScar tissue Neuropathies Neuropathies

* Efficacy has not been established


If the patient is dehydrated, nausea, If the patient is dehydrated, nausea, dizziness, and/or headaches may result.dizziness, and/or headaches may result.

Electrical “shocks” may be reported by Electrical “shocks” may be reported by the patient when MET is applied to scar the patient when MET is applied to scar tissue. tissue. Caused by decreased electrical resistance. Caused by decreased electrical resistance.

Documents

Ch13.Stimulators.fmt