Haemophilia (2002), 8, 413–418

Current concepts in electrotherapy

T. WATSON
Department of Physiotherapy, University of Hertfordshire, UK

Summary. Electrotherapy has an established role in utilized to achieve therapeutic benefit. There appear
the management of a wide range of musculoskeletal to be windows of opportunity related to the magni-
and neurological problems. Used in conjunction with tude of the applied energy, the amplitude of the
other therapeutic interventions, it can make a pos- stimulus and the frequency of application. Tissues
itive contribution to patient care. The means by appear to vary in their responsiveness to these
which a range of different exogenous energy forms factors, and thus an appropriate modality applied
can influence the physiological state of the tissue is in an inappropriate manner will fail to achieve the
well documented. Different therapeutic modalities anticipated effect. This paper aims to review the
achieve their effects in different tissues, and the current concepts of electrotherapy intervention,
clinical decision-making process should employ the taking into account various theories which support
available evidence in order to maximize the potential the principles. Application of various energies in this
benefit for each patient. way can result in significant benefit for the patient.
The applied energy essentially acts as a trigger that
is responsible for stimulating, enhancing or activa- Keywords: electrotherapy, pain management, tissue
ting particular physiological events, which in turn are repair.

The basic principles on which electrotherapy is

Introduction based remain simple through which a wide range of
The role of electrotherapeutic intervention is not new applications can be derived, each of which has its
within the realms of physiotherapy; there is in fact a place in patient care. At its most fundamental level,
long history of electrical, electromagnetic and elec- the application of an external energy to the tissues
trophysical applications that have been employed to can result in the activation, stimulation or enhance-
relieve pain, promote tissue repair and assist in the ment of physiological activity in particular tissues,
restoration of function [1,2]. depending on the mode of energy that has been
The modern-day approach to electrotherapy in its applied.
broadest sense is, however, moving towards a new In order for these effects to be achieved, it is
paradigm that offers the potential for innovative essential that the energy is absorbed in an appro-
applications and approaches. priate tissue. Without absorption, it will not be
Electrotherapy in isolation is rarely the most possible to achieve physiological effects. Once a
appropriate intervention. Whether combined with change has been induced in some physiological
exercise, manual therapy or advice and education, it process(es), the result can be utilized for therapeutic
forms part of a package of care that contributes to benefit [3].
the holistic management of the patient, their family In the clinical environment, it is probably most
and carers. appropriate to start with the patient and their
presenting problem(s). These may be straightforward
(e.g. acute joint pain following a tissue bleed) or
more complex (e.g. reduced mobility in several joints
Correspondence: Dr Tim Watson, Head of Department of
Physiotherapy, University of Hertfordshire, Hatfield, Hertford- as a result of fibrous tissue deposits, soft-tissue
shire, AL10 9AB, UK. shortening and chronic pain syndromes). By identi-
Tel.: + 44 1707 284970; fax: + 44 1707 284977; fying the presenting problems and patient priorities,
e-mail: t.watson@herts.ac.uk it is possible to prioritize the issues and identify the
Accepted 29 January 2002 treatment aims, preferably in conjunction with the

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414 T. WATSON

patient; there is little point is determining the has been achieved (i.e. sufficient current is applied to
patients’ problems without their agreement. achieve the threshold potential), an action potential
is initiated and the nerve will conduct in a normal
physiological manner. The electrical stimulation
Bioelectric cellular activity
serves as the initiator (or trigger) of the action
It is well established that all cells are electrically active, potential [2,7].
not just those of the ‘excitable’ tissues. The cell Stimulation of the sensory nerves can be utilized to
membrane has a membrane potential which averages achieve symptomatic pain relief by means of either
some 70 mV, and this electrical cell membrane activ- the pain gate mechanism or by causing the release of
ity is critical to normal cell function [4]. The level of endogenous opioids [7]. Motor nerve stimulation
electrical activity of the cell membrane influences the will result in some form of muscle contraction, the
general activity level of the cell. If the membrane is nature of which will depend on the frequency of the
electrically quiescent, the cell downregulates, and its stimulus [2].
functional capacity diminishes. Conversely, with Different electrical stimulation modalities will
increased levels of electrical activity, upregulation achieve these effects in different ways, but they have
occurs, and the general cell activity levels increase. a common mode of action. Interferential therapy,
By influencing the activity levels of the cell mem- transcutaneous electrical nerve stimulation and
brane, it is possible to adjust the ‘excitement’ level in faradic stimulation are all different forms of electri-
the cell. This can be achieved with a variety of cal stimulation. Although the machines used to
exogenous energy sources: electromagnetic (e.g. produce each different type of electrical stimulus
shortwave therapies, pulsed or continuous), electrical might be different, the principal effect on the nerve
(e.g. transcutaneous electrical nerve stimulation; tissues is essentially the same.
TENS) or electrophysical/mechanical (e.g. ultra- There are differences in the therapeutic effects
sound) [3]. achieved, as different current forms appear to have a
Each energy source is preferentially absorbed in differential effect on various types of nerve [2,8]. By
different tissue types, hence, the physiological and deliberately selecting stimulation parameters that
therapeutic benefits are achieved in different tissues strongly influence sensory nerves for example, it is
[3]. Ultrasound, for example, is preferentially possible to stimulate normal physiological pathways
absorbed in the dense collagen-based tissues [5] and which induce modulation at the sensory gating
will therefore achieve its best effects in tissues such as system in the dorsal horn of the spinal cord, and
ligaments, tendons, fascia joint capsules and scar thus result in an adjustment of the neuromodulation
tissue. Electrical stimulation (such as TENS) will state of the spinal gating mechanism [7].
primarily affect the nerves, and electromagnetic radio By adjusting the stimulation parameters, different
frequency energy such as pulsed short-wave will be sensory nerves will be preferentially activated and
primarily absorbed in the wet, ionic tissues such as this can result in increased endogenous opioid release
muscle, haematoma and oedematous tissue [6]. in the cord [9]. Both forms of treatment can lead to
symptomatic pain relief, but the physiological mech-
anism by which it is achieved is different, and can be
Modes of application
applied under different circumstances in order to
There are two ways in which exogenous energy can maximize the benefit for a variety of patients.
be applied in order to achieve these changes. Both Activation of the A-beta sensory fibres appears to
will affect the energy system of the cell, and both are be most efficiently achieved with electrical stimula-
applied in current practice. tion at frequencies in the range of 90–130 Hz.
Activation of these fibres influences the pain-gate
mechanisms at spinal cord level, serving to ‘shut the
Higher energy therapies
gate’ and hence reduce the patients perception of
The first method is to deliver an energy form that will pain. The A-delta sensory fibres are most efficiently
overcome the electrical activity of the cell membrane stimulated with much lower frequencies (in the
and thus force the cell to change its ‘excitement 2–5 Hz range). The result of such activation induces
levels’ and hence its activity. Electrical stimulation in the release of endogenous opioids in the cord and
its various forms appears to work in this way. The thus brings about pain relief by means of a different
electrical current passed through the tissues will mechanism. The stimulator used to achieve these
cause the nerve membrane to depolarize and initiate results appears to be less important than the
a depolarization potential. Once the depolarization frequency of the applied stimulation.

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 CURRENT CONCEPTS IN ELECTROTHERAPY 415

The commonality of electrical stimulation modes If the energy is delivered at the appropriate level, a
in use within physiotherapy is that the nerve is the significant effect can be achieved. If too little energy
target tissue. It is possible to employ alternative is applied, the trigger will be insufficient to bring
modes of current application in order to influence about the desired effect. If too much energy is ap-
tissues other than the nerves. For example, small DC plied, however, it appears that the tissues will be
currents can be utilized to influence the healing overloaded, and the desired effect will not be
responses of the musculoskeletal tissues [10] and achieved [17]. The concept of energy windows is
interferential therapy has been employed to enhance gaining credibility, and alongside this, there also
fracture healing [11]. appear to be amplitude windows and frequency
windows [18–21].
If it can be imagined that any particular tissue in a
Low-energy therapies
normal or pathological state is susceptible to some
A second approach to exogenous energy application form of energy, provided it is delivered in sufficient
involves the use of much lower energy levels. quantity with an appropriate frequency and ampli-
Examples of these modalities include low-intensity tude, it is easy to imagine how electrotherapy
laser therapy, in which the power output of the light applications can achieve significant results. If the
is in the range of a few milliwatts rather than the modality is delivered at an inappropriate energy level
magnitude of surgical and other destructive lasers. and/or frequency and/or amplitude, it is clear that
Therapeutic ultrasound will typically deliver a power there are many different ways in which the poten-
output of less than 1 W cm–2. This energy is there- tially appropriate modality can fail to achieve the
fore delivered at levels which are insufficient to bring desired result [3]. Work is currently in hand that
about significant heating of the tissues. The effects aims to utilize the available evidence to determine the
are essentially ‘non-thermal’, although there must be scope and position of the energy, frequency and
a thermal component with any energy absorption. amplitude windows, thereby increasing the likeli-
The intention with modalities such as laser therapy, hood of delivering the most effective modality at the
pulsed short-wave therapy and ultrasound is to bring most appropriate dose for the desired outcome.
about an increase in cell membrane activity (usually There exists substantial evidence in relation to
by influencing a variety of ion gates or channels), and electrotherapeutic modalities. Not all the evidence is
by doing so, to bring about a change in cell state supportive of these applications. Rather than con-
without overt heating effects [3,12]. sidering these to be ‘negative’ publications, one could
Maxwell considered the effects of therapeutic consider that these publications are positive in that
ultrasound at cellular and subcellular levels, raising they are assisting in establishing the position and
several interesting points with regard to possible magnitude of these windows of opportunity, and
tissue effects of the intervention [13]. Examples of hence refining the clinical decision-making process,
clinical applications that have demonstrated signifi- improving the quality of patient care and minimizing
cant benefit include tendons [14], and a range of wasted interventions.
other musculoskeletal tissues [15]. There is no ‘magic’ to the application of electro-
It has been demonstrated that ‘non-thermal’ effects therapy in the clinical environment. There is no one
can strongly influence the tissues, inducing significant single modality that will achieve the best results
changes in tissue activity [16]. By utilizing the energy under all circumstances. The plethora of different
mode that is preferentially absorbed in the target machines can be reduced to a limited number of
tissues it is possible to trigger a range of physiological energy types. Each energy mode will have applica-
changes that can be subsequently employed to tions for which it is more effective and others for
achieve therapeutic benefit. which it is less so.
This principle also holds true for other therapeutic
interventions, whether manual therapy to increase
Windows of opportunity
mobility in a soft tissue, or a particular form of
Given the wide range of electrotherapies currently analgesic medication for pain relief.
being applied in clinical practice, it is important to
consider their mode of action, the tissues that are
Patient responsiveness
preferentially targeted and the energy levels required in
order to best achieve these effects. There is a substan- One of the factors which causes difficulties in both
tial evidence base to support the application of these electrotherapy research and in clinical practice is
therapies in a variety of pathologies, yet not in others. the fact that patients with apparently identical

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416 T. WATSON

conditions will respond differently to identical treat- Although the pattern of electrical activity may be the
ments. As previously, this is not unique to the same, the magnitude can vary considerably between
application of electrotherapeutic modalities. Other individuals [23].
forms of physical therapy generate similar results; a By measuring the magnitude or pattern of the
particular form of manual therapy may achieve naturally produced electrical signals derived from
exceptional results in one patient, yet that same such tissues, it may be possible to infer the patients
treatment, delivered by the same therapist, may potential responsiveness to a particular form of
achieve little benefit in another patient with an therapy. Far from being a hypothetical concept,
apparently identical problem. Similarly, many forms several researchers have been investigating these
of drug therapy cannot be assured to bring about an principles with some success Although at the present
identical result in all patients. time it is not possible to make such definitive
It is of interest to speculate as to why some patients statements with regard to predicted outcome, it
respond so positively, while others derive little or no may well become one of the tools by which such
beneficial effect. If it were possible to pre-screen the judgements will be made in the future [22].
patients into groups, such that the membership of a
particular group would enable the therapist to
Special client groups and electrotherapy
predict whether a positive or zero outcome effect
was most likely, the efficacy of such interventions A brief mention should be made in relation to
would be significantly improved. In order to be able particular circumstances that affect haemophilia
to achieve this screening, it is essential to understand patients with respect to electrotherapy. Firstly, the
why it is that patients respond in such different ways. issue of application of electrotherapy modalities to
Given the present levels of knowledge, it is not children. It is difficult to find detailed documentation
possible to predict the treatment outcomes with in this respect, but it is a widely held consensus view
accuracy. Laboratory and clinical evidence can of experts in the field that it is acceptable to treat
certainly assist in predicting which mode of inter- children with electrotherapy modalities, with the
vention is more or less likely to gain the optimal general exception of the active epiphyseal regions.
results. Knowing that treatment A is more likely to The problem here is that the external energy may
be effective than treatment B is a useful baseline from adversely influence the active region, although there
which to make a judgement, but further refinement is no specific evidence to show that this is the case.
of the clinical decision-making model will only be A second circumstance that is generally held as a
achieved with the publication of additional clinical contraindication for electrotherapy modalities is
outcome trials. tissue where bleeding is active or where there is the
At some point in the future, it may be possible to possibility of tissue bleeding. The risk here is that
suggest with some accuracy that a younger patient most electrotherapy interventions appear to cause an
with a haemarthrosis will respond preferentially to, increase in local blood flow, and to do this in tissues
say, active exercise and ultrasound while an older that are bleeding could clearly have an adverse effect.
patient with a similar problem, may respond prefer- Given that both of these circumstances could
entially to the application of pulsed short-wave reasonably be expected to come into play in the
therapy. This assumes of course that age is a primary management of haemophilia patients, especially in
factory in considering outcome in patients treated the immediate postbleed treatment phase, there is a
with an acute haemarthrosis. It may be that the need for further controlled trials to determine the
critical parameter is not age, but sex or height or magnitude of the ‘adverse effects’ and the relative
weight or lean body mass. Given the number of risk.
potentially important variables, it less than surpri- In the absence of such data, it is the view of experts
sing that full documentation of the permutations has in the field that electrotherapy can be applied to
yet to be achieved. patients who have haemophilia, so long as they are
One area that offers potential for differentiating covered by the appropriate factor replacements thus
between patients in this way relates to their endo- dealing with the ‘tissue bleed’ scenario. When it
genous bioelectric activity. All musculoskeletal tissues comes to the treatment of children who have
are electrically active and the magnitude of this experienced a haemarthrosis, for example, it is a
activity varies between individuals [22]. All ‘normal’ matter of relative risk. There is a theoretical (but
individuals appear to present with a common pattern unproven) risk that electrotherapy intervention may
of electrical activity, whether one is considering the adversely affect the active epiphyseal region, yet at
electrical potentials of the skin or those of the tibia. the same time, there is a risk associated with not

Haemophilia (2002), 8, 413–418 Ó 2002 Blackwell Science Ltd

 CURRENT CONCEPTS IN ELECTROTHERAPY 417

actively treating the haemarthrosis condition as soon An electrotherapy modality applied in the most
as possible postbleed. In the absence of any more appropriate circumstances should be able to achieve
detailed data at the present time, it is suggested that significant benefit. Applied at a less than fully
it could be considered appropriate to use electro- appropriate energy level, amplitude or frequency, it
therapy intervention postbleed in children (e.g. is likely to ‘miss the mark’ and a less beneficial
pulsed short-wave for acute knee or ankle haem- outcome may result. Further refinement of the
arthrosis), on the basis that the relative risk of the treatment paradigms is essential, but given the
adverse effects of the intervention are less problem- knowledge and evidence base to date, quality inter-
atical than the relative risk of not treating the vention is already possible. The more evidence that is
problem (i.e. long-term joint dysfunction). generated, the more refined the decision-making
It is considered important to conduct controlled process will become.
trials for electrotherapeutic intervention in these As one part of the therapeutic armoury, electro-
patient groups in order to establish the benefits of therapy has a well earned place in the modern
the therapy, thus enabling the risk/benefit analysis to management of patient problems. Its use in combi-
be considerably more accurate. nation with other forms of physical therapy, e.g.
manual therapy, exercise therapy, postural correc-
tion and patient education, is likely to achieve the
Future developments
most significant results. Used inappropriately, it is at
New electrotherapy modalities are introduced into best ineffective. Using the evidence base to enable
the clinical environment with alarming regularity. quality decision-making and treatment is the route
They are often not fully evidenced in terms of their by which the efficacy of this type of intervention will
mode of action, nor their physiological and/or be improved.
therapeutic effectiveness. Laboratory and clinical
trials are essential in order to evaluate these inter-
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Haemophilia (2002), 8, 413–418 Ó 2002 Blackwell Science Ltd