Post on 23-Jan-2018
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A.THANGAMANI RAMALINGAMPT, MSc (PSY), MIAP
Almost 60 yrs old, popular last 25 years with numerous uses.
Waveform: • Twin-peak monophasic pulse
• phase duration: 25s, sometimes adjustable
• comfortable but weak current; polarity present but electrochemical (net DC) effect not harmful. Typical stimulation time does not exceed 1 hour
• Upto200µs
• Voltage more than 100 volts
Wound healing
Oedema reduction
Pain modulation
NMES
On vascular system
Amplitude (based on desired excitatory
response)
Pulse Rate (related to pain control theory
or motor response needed)
Mode - Continuous, Ramp-Surge,
Alternate
Robert Becker – 1962Theory - “Current of Injury”
• normal bioelectric system, nonexcitable tissues have a charge skin ----- deeper tissues +++++ neuraxis ++++++ periphery -------
• Wounds - system is disturbed & creates a “current of injury” that initiates tissue healing . . . inflammatory process, migration of cells, etc..
• Use of E-stim magnifies the “current of injury” to initiate, maintain, or speed the process.
Further research established• Wound tissue is (+) & skin
around is (-); this difference is the “skin battery” or “current of injury” and must exist for proper healing; if it fails or is disrupted, then slow/no healing can occur. E -stim can help restore the “skin battery”.
Further supported by evidence that many chronic wounds lost (+) polarity; e-stim w/ the anode (+) over the wound enhanced healing. (using DC)
If healing plateaued, switching polarity = good outcome
Monophasic twin-pulse current (HVPC)105 ppsAmplitude: submotorTime - 45 min, 5 days a weekWound packed with soaked gauze and
anode (+) placed over woundCathode placed 15 cm away, proximalRationale: Done to amplify the “current of
injury”
A naturally occurring process whereby signaling/messenger systems work via bioelectrical mechanisms. (Does not contradict the chemical model of human physiology; “chemotaxis”).
Process can be corrected and/or
enhanced by attraction of cells to the
wound thru use of anode (+) or cathode (-)• Leukocytes, fibroblasts, endothelial & epithelial
cells, etc.. all have polarity and can be electrically
attracted.
Treatment polarity depends on stage of
the wound
Monophasic twin-pulse current (HVPC)100 pps, no mention of pulse width Amplitude - just below motorTime - 60 min, 5 days a weekWound packed with soaked gauze Polarity - based on wound stateOther electrode placed 15 - 20 cm away
(proximal) to complete the circuitDone to amplify the “injury potential” or
“current of injury” and produce “galvanotaxic attraction”
Options• Directly over the wound
• Directly in the wound *
• Straddle the woundWOUND TREATED
Burns
Post surgical wounds
Hand injuries
Venous ulcers
Diabetic ulcers
6µA-1.4mA of DC current stills the growth
of micro organisms.
Current disrupts the homeostatic
mechanism of the organism.
Anodal current
Cathodal current
Dermal cell movement
Germicidal effect
Sedative effect
Increases blood flow
Germicidal effect
Clumping of leucocytes
Why not use LIDC ??: Studies have shown it to be effective• Much longer Rx time and
greater frequency of Rx
• electrochemical changes more pronounced & potentially harmful (due to pH changes in tissue)
HVPC has a shorter Rx time and less frequent, no harmful electrochemical changes in the tissue
Mechanisms by which biphasic or AC may enhance healing are not well-understood.
ESTR usually not used on well-healing wounds, more for chronic wounds
DOES NOT replace typical wound care
Suggest physician cooperation/agreement
Patient tolerance or refusal a potential issue based on the way you describe it.
OsteomyelitisMalignancies / neoplasmsCarotid sinus / laryngeal ms.Thru the thoraxDemand-type pacemakersOver topical agents containing metal ions
(iodine, mercurochrome)Others as previously learned; except for open
tissue
Negligible thermal& electrochemical effects
Cannot be used to treat denervated
muscles
Electrical stimulation for the treatment of wounds will only be covered for chronic Stage III or Stage IV pressure ulcers, arterial ulcers, diabetic ulcers and venous stasis ulcers.
All other uses of electrical stimulation for the treatment of wounds are non-covered.
Chronic ulcers are defined as ulcers that have not healed within 30 days of occurrence.
Electrical stimulation will not be covered as an initial treatment modality.
Electrical stimulation will be covered only after appropriate standard wound therapy has been tried for at least 30-days and there are no measurable signs of healing. This 30-day period can begin while the wound is acute.
Measurable signs of improved healing include a decrease in wound size, either surface area or volume, decrease in amount of exudates and decrease in amount of necrotic tissue. Standard wound care includes: optimization of nutritional status; debridement by any means to remove devitalized tissue; maintenance of a clean, moist bed of granulation tissue with appropriate moist dressings; and necessary treatment to resolve any infection that may be present.
Continued treatment with electrical
stimulation is not covered if measurable signs
of healing have not been demonstrated within
any 30-day period of treatment.
Electrical stimulation must be discontinued
when the wound demonstrates 100 per-cent
epithelialzed wound bed.
This service can only be covered when
performed by a physician, physical therapist,
or incident to a physician service.
Based on the results from animal studies, HVPC may have an effect upon acute edema FORMATION but the effect is short-lived (several hours); therefore, treatment is recommended for 30 minutes every 4 hours for the period of time that bleeding/swelling is expected to occur. This treatment duration and frequency fits well with the RICE protocol but may often be too frequent for an individual needing/trying to function (work or school). A portable HVPC unit is essential (and available)
This treatment is indicated for acute
trauma (sprain, strain, contusion) or post-
surgery. The situation must be an ACUTE
TRAUMATIC CONDITION where
bleeding, swelling & inflammation are
actively developing. The underlying
physiological effect is largely unknown but
studies often point toward an effect upon
capillary permeability - related to
histamine release.
STAGE Rx CURRENT Polarity FREQ RESPONSE TIME
ACUTE Control of
Formation
HVPC (--) 120 PPS SUBMOTOR 30 Min/
4 HRS
during
acute
stage
SUBACUTE
I CHRONIC
Reduction HVPC
BIPHASIC
RUSSIAN
N/A Varies:
need ms.
pump
MOTOR 20 min
daily
It is basically a variation of sinusoidal currents. Sinusoidal currents are alternating low frequency currents, having frequency of 50 Hz and pulse duration of 10 msec, providing 100 stimuli / sec.
: There are five different currents
available for didynamic therapy. 1. DF (Fixed di-phase):Full-wave rectified alternating current,
with a frequency of 50 Hz. 2. MF (Fixed mono-phase):Half-wave rectified alternating current,
with a frequency of 50 Hz. 3. CP (Short periods):
I-sec DF I-sec MF I-sec DF
Equal phases of DF and MF, alternating without interval pauses.
4. LP (Long periods):10-sec MF 5-sec DF 10-sec MF
It includes 10-sec phase of MF, followed by 5-sec phase of DF, in which peak intensity is varied with a frequency to rise and then fall.
5. RS (Syncopal Rhythm): It comprises 1-sec phase of MF,
followed by a 1-sec rest phase.
Physical properties
* Pain masking (increase of the stimulation threshold):By DF current, stimulation of the sensory nerves may not always cause excitation but it can be altered.
* Vasodilatation and hyperemia: Due to release of histamine in the tissues. The same can occur in deeper structures by reflex activity.
* Muscle fibers stimulation: Didynamic current stimulates the muscle fibers, causing muscle contraction. CP and LP currents stimulate increase blood flow to the muscle and reduce edema.
* Stimulation of vibration sense: This leads to central masking of pain sensation.
Didynamic stimulation causes relief of pain and edema in the following conditions:
Soft tissue injury (sprains, strain, contusion and epicondylitis).
Joint disorders (post-immobilization and arthritis).
Circulatory disorders (Raynaud's disease and migraine).
Peripheral nerve disorders (neuralgia and sciatic neuritis).
* Open skin: The current tends to concentrate at this point; small broken areas can be insulated by Vaseline.
* Bony areas: It may produce burn.* Loss of sensation: It can produce burn.* Skin lesions: Eczema fungi can be irritated and
made worse.* Infections: It may cause spreading of infection.* Thrombosis.* Cardiac pace makers.* Superficial metal.
* Intensity: It should be increased gradually until definite vibration or prickling sensation occurs.
* Duration: Not more than 12 minutes; each type for 3 minutes.
* Frequency: Daily or every other day for 12 sessions.
DF: It is used for the initial treatment and before application of other currents. The patient feels a prickling sensation, which subsides after a short time.
- MF: The patient feels a strong vibration for longer time than the sensation of DF. It is used for treatment of pain without muscle spasm.
- CP: In DF phase, there are fine tremors in MF phase (strong and constant vibration). There are rhythmic contractions, being used for treatment of traumatic pain.
- LP: It has a long-lasting analgesic effect. It is used with combination of CP in treatment of neuralgia.
- RS: It can be used for faradic stimulation of the muscle and as a test for motor nerve excitability.
“low-intensity direct current that delivers monophasicor biphasic pulsed microamperage currents across the intact surface of the skin’’
MET uses currents that are 1/1000th of an ampere smaller than those delivered by standard TENS devices (milliamperes)
Microcurrent electrical nerve stimulationMicroamperage stimulationLow-intensity direct current and Pulsed low intensity direct current
Microcurrenteffect600 HzSkinSurface500 HzSkin subSurface300 HzLymphatic
stimulation20 HzCirculation10 HzFacial muscles0.8 HzDeep facial Waveform shapeMicro-
current effectSineSuperficialSquarePumpingRectangularLiftingSawtooth
(Ramp)Longer lifting
Specifications
Channels :Dual
Power Source :9V alkaline
battery
Output Voltage :12 volts
Timer :20, 40 min and
constant
Frequency :0.3, 8 and 80Hz
Alleviation of
Pain
Inflammation
Spasm
Promotion of
Healing
Osteoarthrotis
Osteoporosis
Sports injuries
Fractures
Wounds and
Ulcers
Sinusoidal currents are evenly alternating
sine wave currents of 50Hz, the form of
the UK mains current (see Fig. 3.4). This
gives 100 pulses or phases in each
second of 10 ms each, 50 in one direction
and 50 in the other. It can be produced
from the mains by reducing the voltage to
60 or 80 V with a step-down
transformer.
Indicated to introduce ions into the body using direct current
Advantages are it’s painless, sterile, noninvasive
Phonophoresisdelivers whole molecules across the skin into the body.
Iontophoresis delivers ions into the tissues.
Both are noninvasive means to delivers chemicals to the body
Negatively charged electrons are repelled from the cathode. Thus negatively charged electrons move toward the positive pole where they create an acid reaction.
Positively charged ions are attracted to the negative electrode creating an alkaline reaction at the cathode
Positively charged ions are driven into tissues from the positive pole
Negatively charged ions are driven into tissues from the negative pole
Therefore you must know the polarity and match it with the appropriate electrode
Ion flow is dependent upon:• Tissue impedance
• Strength of current field
• Ion migration is caused by the potential difference in current density between the active and dispersive electrodes
Adjusted by: 1. Intensity
adjustments 2. Changing the size
of the electrode
Directly related to:
• 1. Intensity of the
current (density at the
active electrode)
• 2. Duration of current
flow
• 3. Concentration of
ions in solution
Low amp more effective than higher current intensities
Higher intensities reduce effective penetration to tissues
Usually between 3-5 ma Increase the intensity
slowly- WANT pt to Report “Prickling” or “Tingling”
Pt reports of Burning or Pain mean STOP!!
Slowly decrease intensity to 0 when terminating treatment
Remove electrodes Max current intensity may
be determined by the size of the active electrode.
Current amplitude is set so that the current density falls between .1-.5ma/cm2
10-20 minutes Average 15 Check skin every 3-5
minutes
Only use compounds soluble in both fat and water Penetration <1mm
Heavy metals tend to become insoluble precipitates inhibiting their penetration
Negative ions at anode produce acidic reaction via formation of HCL.
Pos ions at the cathode produce alkaline reactions, forming sodium hydroxide
Table 7-1. Recommended Ions for Use By Therapists42
POSITIVEAntibiotics, gentamycin sulfate (+), 8 mg/mL, for suppurative ear chondritis.Calcium (+), from calcium chloride, 2% aqueous solution, believed to stabilize the
irritability threshold in either direction, as dictated by the physiologic needs of the tissues. Effective with spasmodic conditions, tics, and "snapping fingers" (joints).
Copper (+), from a 2% aqueous solution of copper sulfate crystals; fungicide, astringent, useful with intranasal conditions, e.g., allergic rhinitis or "hay fever," sinusitis, and also dermatophytosis or "athlete's foot."
Hyaluronidase (+), from Wydase crystals in aqueous solution as directed; for localized edema.
Lidocaine (+), from XYLOCAINE 5% ointment, anesthetic/analgesic, especially with acute inflammatory conditions (e.g., bursitis, tendinitis, tic doloreux, and TMJ pain).
Lithium (+), from lithium chloride or carbonate, 2% aqueous solution, effective as an exchange ion with gouty tophi and hyperuricemia.
Magnesium (+), from magnesium sulfate ("Epsom Salts"), 2% aqueous solution, an excellent muscle relaxant, good vasodilator, and mild analgesic.
Mecholyl (+), familiar derivative of acetylcholine, 0.25% ointment, is a powerful vasodilator, good muscle relaxant, and analgesic. Used with discogenic low back radiculopathies and sympathetic reflex dystrophy.
Priscoline (+), from benzazoline hydrochloride, 2% aqueous solution, reported effective with indolent ulcers.
Zinc (+), from zinc oxide ointment, 20%, a trace element necessary for healing, especially effective with open lesions and ulcerations.
NEGATIVEAcetate (-), from acetic acid, 2% aqueous solution; dramatically
effective as a sclerolytic exchange ion with calcific deposits.Chlorine (-), from sodium chloride, 2% aqueous solution, good
sclerolytic agent. Useful with scar tissue, keloids, and burns.Citrate (-), from potassium citrate, 2% aqueous solution, reported
effective in rheumatoid arthritis.Dexamethasone (-), from Decadron, used for treating musculoskeletal
inflammatory conditions.Iodine (-), from "Iodex" ointment, 4.7%, an excellent sclerolytic agent,
as well as bacteriocidal, fair vasodilator. Used successfully with adhesive capsulitis ("frozen shoulder"), scars, etc.
Salicylate (-), from "Iodex with methyl salicylate," 4.8% ointment, a general decongestant, sclerolytic, and anti-inflammatory agent. If desired without the iodine, may be obtained from MYOFLEX ointment (trolamine salicylate 10%) or a 2% aqueous solution of sodium salicylate powder. Used successfully with frozen shoulder, scar tissue, warts, and other adhesive or edematous conditions.
EITHERRinger's solution(+/-), with alternating polarity for open decubitus
lesions.Tap water (+/-), usually administered with alternating polarity and
sometimes with glycopyrronium bromide in hyperhidrosis.
Analgesia
Scar modification
Wound healing
Edema
Burns
RSD
Inflammatory MS
conditions
CA++ deposits
Hyperhidrosis
M spasm
Fungi open skin
lesions
Herpes
Gout
Skin sensitivity reax
Sensitivity to agent
Gastritis/ulcer-
cortisone
Asthma-mecholyl
Sensitivity to metal
Sensitivity to seafood-
iodine
Recent scars in
treatment area
Metal implants close
to skin
Acute injury where
there is still bleeding
PPM