Electrical Stimulation

Prepared by: Floriza P. de Leon

Direct Vs Alternating Current

Direct Current

Alternating Current

Flow of Electrons Examples

Unidirectional Galvanism Iontophoresis

Changes periodically and Low, medium, and high frequency modalities

Low Vs Medium Vs High Frequency Current

Low
Frequency Examples Skin resistance Skin Discomfort Effect Nerve Stimulation 1-2000 Hz

Medium
3000-6000 Hz

High
>500,000 Hz SWD, MWD, US None

Sinusoidal and Interferential faradic currents therapy, TENS High Little to none Cause discomfort Stimulate nerve yes

w/ no discomfort None Block pain yes Thermal No

Definition of Terms

Frequency number of cycles per second (Hz or pulse/sec); actual frequency of stimulus train where pulses are produced at regular intervals Mean frequency value used for non uniform stimulus trains where pulses are produced at irregular intervals, or for mixed frequency stimulation where more than one frequency is produced during a period of stimulation Amplitude peak to peak amplitude of the cycle and is expressed in mAmp or volts; high voltage stimulators deliver peak outputs of around 150 V and low voltage stimulators of 100 V or less Pulse duration aka pulse width; duration of the output pulse waveforms at 50% of the maximum amplitude (us) Charge density amount of energy applied to the stimulated tissue per pulse; pulse duration x current

Waveform shape of a pulse

Galvanic current continuous unidirectional current nterrupted Direct Current (IDC) when galvanic current is interrupted by periods when no current is flowing

Definition of Terms

Alternating Current often delivered at high frequencies that lowers skin impedance and thus delivers more current to the motor nerves Interference-modulated current current produced by the interference pattern produced in the tissues by two slightly different high frequency (4000 Hz) sine waves; known as interferential current Burst-Modulated alternating current aka Russian stimulation; high frequency (2500 Hz) carrier current is interspersed with 10 ms periods when no current is flowing, producing 50 burst per second Symmetrical biphasic waveforms when the shape and amplitude of the pulse is identical in both positive and negative directions

Definition of Terms

Sine wave an example of symmetrical biphasic waveforms Asymmetrical biphasic waveform shape and amplitude of the pulse is not identical in positive and negative directions Duration of stimulation time for which stimulation was applied (hours or mins) Duty cycle comprised of an on time reflecting duration of pulse delivery, and an off time duration of quiescence Ramping gradually increase the charge applied to the tissue and hence increase the intensity of mm contraction attained; achieved by a gradual increase in the amplitude or the pulse width of the pulse train; allows for accommodation of the nervous tissue-to-pulse delivery

The Importance of Stimulation Parameters

Waveform

galvanic stimulation is only useful for stimulating denervated muscle whereas IDC, including faradic stimulation is able to stimulate innervated muscle galvanic and IDC both create thermal and chemical reactions under the electrodes and are often painful and therefore should be used be caution when stimulating a mm at a constant frequency the only way to increase force produced is to recruit more motor units by increasing the intensity (amplitude of the waveform) of stimulation most suitable pulse duration for motor stimulation of triceps was found to be between 20 and 200 us, the most comfortable being 100 us pulse duration less than 100 us were suitable for sensory stimulation cutaneous stimulation of healthy mm selectively activates nerve endings and not the mm fibers directly Slow rising pulses of long duration selectively stimulate denervated muscle, as opposed to fast rising pulses of short duration that stimulate innervated mm

Amplitude

Pulse Duration

Notes

Basic Electrode System Used for Electrical Stimulation

Malleable metal electrode such as triplate or aluminum with pad of lint, cotton gauze or sponge material at the end

Pad/gauze or sponge is wet with water before being applied to the skin to provide a uniform ion-containing low resistance pathway for the current, the material keeps the water in place May use ordinary tap water Electrodes kept in place with bandages, straps suction Thickness of pad depends on amount of water needed, this depends on irregularity of the surface to be treated and degree of chemical reaction desired If electrodes are unequal in size smaller electrode is active and most effects will occur here; other electrode is the indifferent or dispersive electrode May use button electrode for very small motor points

Basic Electrode System Used for Electrical Stimulation

Electrodes that conform to the body surface

Made of carbon-impregnated silicon rubber May be used with sponge pads or coupled to skin with thin layer of conducting gel Kept in place with strap or adhesive tape Carbon rubber and similar electrodes convenient for long term use and repeated self-application by px Water pad conduction methods, whether metal or carbon rubber electrodes, more appropriate for larger treatment areas with higher currents Carbon rubber less efficient in passing current compared to the metal electrodes which have a lower impedance Carbon rubber however, has lower impedance compared to available polymer electrodes Note: if electrode is coupled to skin by a wet pad, current density is determined by the area of the pad, however, if it is applied in direct contact with the skin area is determined by the electrode

Basic Electrode System Used for Electrical Stimulation

Water Bath

Used for hand, forearm, foot and leg which is placed between the electrodes Provide a large area for the indifferent electrode and for applying muscle stimulating currents Current density depends on location of electrodes

Factors That Affect Current Flow

Quantity of current flow and path to be followed depends on impedance of the pathway Impedance includes: ohmic resistance; capacitive resistance/reactance; inductive resistance (negligible in tissues) Ohmic resistance:

Determined by thickness and nature of skin under the electrodes primarily and Inter-electrode distance secondarily High ohmic resistance: epidermis (highest), bone and fat Low ohmic resistance: watery tissue such as blood, mm and nerve

For slowly changing current and direct current, skin resistance is high so most electrical energy is released in the skin and subcutaneous tissues thus, cutaneous nerves are stimulated Short pulse (phase) lengths penetrate skin more easily

To stimulate deeply placed low-threshold nerves (motor nerves) use shorter pulse of about 1/20th of a millisecond (0.45/5 ms) because of skin capacitance To stimulate high threshold unmyelinated pain fibers (C fibers) in skin use longer pulses of a few milliseconds

Technique to Reduce Electrical Resistance at Skin Surface

Wash surface to be treated to remove some of the keratin and sebum and leave skin wet Warm skin which will increase rate of particle and ionic movement Scrape surface of sandpaper surface if small currents will be used

Possible Areas of Abnormal Resistance

Low resistance cuts, abrasions (may be protected with a thin layer of petroleum jelly and covered with cotton wool) High resistance warts, scars, grease/emollients

Arrangement of Electrodes

Increasing the size of the electrodes will decrease current density Adding one or more parallel electrode will also decrease current density For carbon-rubber electrodes may have slightly higher current thru region where wire enters electrodes Use small electrode to give high localized current density applied over motor point or acupuncture point; dispersive electrode placed close to it the further away the dispersive electrode is placed the more current is needed and less effective localization will occur For same sized electrodes current density under each will be similar thus sensory stimulation will occur in both areas if electrodes placed close together effect will be localized to the region between electrodes and at adjacent edges; if electrodes are placed at either end of the long axis of the belly of a mm then the mm will be stimulated

Important Safety Precaution

Turn the power switch on before connecting patient to the circuit to prevent a spike in the output Current density for any electrode/skin contact area should not exceed 2 mA ms/cm2

Unipolar Vs Bipolar Motor Point Stimulation

Unipolar Motor Point Stimulation Electrodes Used Bipolar Motor Point Stimulation

One small active Equal sized electrodes electrode and one large dispersive electrode Motor point for stronger response Same amount of current passes thru each electrode Smaller sized electrode will have higher current density, thus effects here is stronger (active electrode) Effect depends on placement Current density equal in both electrodes Convenient for stimulating mm groups or very large mm Equally small electrodes used for stimulating denervated mm

Site of Stimulation Description

Ways in Which Electrical Current Can Cause Tissue Damage

Direct or uniphasic currents cause electrochemical damage called chemical burns Currents with varying rates that stimulate mm or nerve may cause damage if an excessively strong or prolonged mm contraction is elicited; this is particularly dangerous if the heart mm is involved as this may stop circulation Currents of sufficient intensity may cause heating leading to heat burns

Comparison of Electrical Excitability of Nerve and Muscle

Nerve Resting Membrane -70 mV Potential Accommodation Rate higher Pulse Duration Used Shorter pulse duration for Stimulation Intensity Need for Higher intensities Stimulation (since pulse duration is short) Muscle -90 mv Lower Longer pulse duration Lower intensities (since pulse duration is longer)

Laws Relevant to Neuromuscular Stimulation

Law of Dubois-Reymond

Governs the nerve and mm response to external stimuli States that the variation in current density rather than the absolute density acts as a stimulus to the nerve or mm Intensity of the stimulus and resulting mm contraction are directly proportional to the magnitude and change in current strength Intensity is proportional to rate of fluctuation In order to stimulate the excitable membrane

Amplitude must be high enough Rate of change of voltage must be sufficiently rapid Duration of stimulus application must be long enough

Laws Relevant to Neuromuscular Stimulation

Erbs Law

Normal polar formula of response is CCC>ACC>AOC>COC A continuous direct current can only produce contraction if the circuit is opened (make) or closed (break); closing the circuit causes an increase in irritability at the cathode and a decrease irritability in the anode If a direct current is applied, the surface of the membrane nearer the cathode becomes negative in relation to the opposite surface, while the surface of the membrane nearer the anode becomes more positive. The resting potential increases at the membrane nearer the anode while a decrease in potential differences occurs at the cathode. If the potential difference falls below, this increases the permeability to sodium ions and an impulse is not initiated With the cathode as the stimulating electrode, less current is needed to produce a response than when the anode is used. In other words, the cathode closing contraction (CCC) is greater than the anode closing contraction (ACC) is greater than the anode opening contraction (AOC) is greater than the cathode opening contraction (COC) A reversal of polarity occurs when an injured nerve have undergone degeneration. A greater amount of current is needed to produce a response and ACC>CCC>COC>AOC. This polar inversion has never been satisfactorily explained

Stimulation of Innervated Vs Denervated Muscle

Innervated Type of Contraction 1/secsingle brisk contraction 20/sec partial tetany 60/sec- full tetany Rate of Change of Sudden increase in Current intensity Strength of Contraction Depends on number of motor units activated Intensity higher Pulse duration Pole used Chronaxie Ideal current Denervated Sluggish

Gradual rise in intensity Depends on number of mm fibers activated Lower

Less 10 ms-short pulse More than 10 ms duration longer pulse duration Either terminal Anode < 1 ms > 50 ms

Faradic or faradic type IDC

Comparison Between Anode and Cathode

Anode Charge Ions attracted Polar Effects Positive (+) Anions o o Acid reaction Release of Cl ions Repels metals and alkaloids Anelectrotonus (decrease in nerve irritability) Galvanic hyperemia Drying or hardening effect (unequal electrode size active) sedative Slow, sluggish twitch low 15-30 mins o o Alkaline Reaction Release H ions Repels acids and radicals Catelectrotonus (increase in nerve irritability) galvanic hyperemia softening (active electrode is of unequal size) stimulative Brisk twitch Higher 10-20 mins Cathode Negative (-)

Physiological effects

Type of mm contraction Intensity Duration

Summary of Contraindications to Electrical Stimulation

strong muscle contraction that might cause joint or mm damage; detachment of thrombus, spread of infection and hemorrhage stimulation of autonomic nerves which may alter the cardiac rhythm or other autonomic effects the current might be localized (concentrating its effect) over open wounds or skin lesions such as eczema neoplasm and tuberculous infection electrical stimulation may provoke undesirable metabolic effects if current is not evenly biphasic skin damage and irritation may occur especially if the treatment site is

Therapeutic Direct Current

Therapeutic Direct Current

Direct cuurent refers to a current that passes for more than one second continuously in the direction (unidirectional current) Also called constant current or galvanism or galvanic current Available units medium frequency D.C. type current with pulse duration of 125 us and intervals of 5 us giving a duty cycle of 96%

Transmission

Current is transmitted to the site of stimulation through a metal electrode (conductor) that has a wet pad at the end The effect is a chemical change at the electrode-tissue junction (changes of electrolysis) Nature of the change depends on the available electrolytes at this junction In general, acids form at the positive electrode (anode), while bases form at the negative electrode (cathode) Follows Ohms Law: current in any circuit is directly proportional to the voltage and inversely to the resistance; thus, the intensity to be used also depends on the resistance encountered Resistance here is from the epidermis the larger the cross-sectional area the lesser the resistance

Others

Chemical burns are more likely to occur at the cathode The extent of the chemical change depends on the

Current intensity per unit area or current density Duration of time that the current is flowing

Iontophoresis

Iontophoresis

Movement of ions across a biological membrane by means of an electric current (direct current is used) A drug in ionic form is applied at the end of the electrode which will move to either the cathode or anode depending on whether it is an acid or base; the drug can therefore be introduced into the tissue The amount of drug introduced depends on the current density and duration of treatment thus, dosage is expressed in terms of total current in mA multiplied by time in minutes Current density is limited by the skin tolerance

Prescription

Current density = 0.1-0.5 mA/cm2, others recommend 0.1-0.3 mA/cm2 Duration = 10-30 mins Recommended concentration of the ions in the solution used is 1-2%

Physiological Effects/Therapeutic Use

Direct current

Sensory changes

Mild tingling or pricking sensation which may merge into a mild irritation or itching sensation Localized erythema (will prolonged stimulation), more marked in cathode

Capillary hyperemia (not arteriolar dilatation) Electrotonus depolarization at cathode and hyperpolarization at anode Relief of pain Acceleration of heating Tissue destruction at higher current densities Local anesthesia Relief of idiopathic hyperhidrosis (this is probably the most common purpose for doing iontophoresis at present) Application of drugs such as antibiotics and anti-inflammatory drugs; use of vinca alkaloids has been used in iontophoresis to relieve neurogenic pain

Iontophoresis

Contraindications for Ion Transfer

Anesthetic skin in area to be treated Recent scars in treatment site Metal embedded close to skin of treatment site Acute injury if active bleeding is still present Patients with cardiac pacemaker

Transcutaneous Nerve Stimulation

Definition of Terms

Carry-over: refers to the period after removal of TENS where the px remains pain-free TENS units with a short carry-over by mechanism of action may clinically increase the length of the pain-free period after TENS treatment by breaking into the painmuscle spasm cycle or reduce muscle guarding Adaptation: a physiologic phenomenon which clinically presents as a patient who no longer experiences the same amount of relief with the same dosage of the TENS thus, the amplitude or pulse width has to be increased to get the same effect Parameter ranges: refers to the stimulus strength used expressed as the pulse width, pulse rate and amplitude

Electrode Placement of TENS

Four approaches to be considered

Usual practice is to apply the electrodes close where the pain is felt Within dermatome, sclerotome, or myotome where pain is felt, placed to pass current through the long axis of the dermatome Over trigger or acupuncture points, located by their lower resistance compared with surrounding skin (due to active sweat glands and/or local vasodilation) Over peripheral nerve, placed in the line of the nerve where it is superficial, this method is primarily used in the treatment of neurogenic pain such as post-herpetic neuralgia

Ultimately technique used is which ever is most effective

Prescription

Most often given as short pulses of about 0.05 ms at 50-100 Hz referred to as Conventional TENS is a high frequency, low intensity stimulation Intensity turned up gradually until prickling or tingling sensation is felt; intensity should not cause pain nor stimulate a muscle contraction Recommended duration and timing: 30-60 min; session o.d. or b.i.d to continuous TENS for minimum of eight hours up to 24 hours

TENS: Hyperstimulation

Description

A form of neuromodulation that uses noxious input to control pain A painful stimulus is used to inhibits pain Parameter ranges: pulse width = 250 us to 10 ms

Pulse rate = 1-4 pps Amplitude = to point where px can tolerate the noxious stimulus

To further increase the current density a small diameter point-probe active electrode is used, since the surface area of the electrode is small compared to the unit output, the current density is high Hyperstimulation analgesia may also be produced by other techniques such as dry needling, acupuncture, intense cold or heat, mechanical pressure or chemical irritation of the skin thus, technique use may be

Non invasive (surface) stimulation or Invasive stimulation Stimulation mode combined with Stimulation mode combined with Skin resistance or point locating modes

These TENS units have

These TENS units have

The point where the noxious input is to be made is identified by putting the unit on the point locating mode first, the point is identified through the meter reading or an audible signal, once this is located the unit is now stretched The point where the noxious input is to be made is identified by putting the unit on the point locating mode first, the point is identified through the meter reading or an audible signal, once this is located the unit is now stretched to the stimulation mode for the noxious input which is transmitted through an electric current

Purpose and Effect

Relief pain through the brainstem which will in turn inhibit pain at the spinal level Noxious stimuli excite small pain fiber this activates the brainstem reticular formation info from reticular formation excites the midbrain periaqueductal gray area which has a high concentration of opiod peptides descending antinociceptive pathway is activated pain signals at spinal cord is inhibited

Advantages Fast-onset analgesia Areas that are difficult to reach by large electrodes such as the face, scalp, ear and bony prominence can easily be treated with the small, active point electrode Disadvantage: unpleasant noxious stimulation may not be tolerated by px Indications: acute or chronic pain Contraindications: same as conventional TENS

Interferential Stimulation

Interferential Stimulation

Produced by passing two medium frequency alternating currents which are slightly out phase through the tissues; where two currents intersect a new current is set up As mentioned earlier this is done to allow nerve stimulation because of the amplitude modulation (a single medium frequency current will not effectively stimulate nerves the way a low frequency current can Secondly, being a medium frequency current it passes through the skin unlike low frequency currents that encounter skin resistance Is therefore, a method of producing low frequency alternating currents selectively at any tissue depth without the problem of skin resistance Principle: two medium frequency alternating currents which are slightly out of phase are applied simultaneously through the tissues. A new current is set up where the two currents intersect (interferential current). In the area where the two currents are heterodyned, the intensity of the combined currents will increase and decrease rhythmically. This is the interference effect. The combined current has a BEAT FREQUENCY which is the difference between the two medium frequencies

Interferential Stimulation

When two peaks of amplitude which are of the same direction coincide, the resultant amplitude is at a maximum; when they are in the opposite direction they cancel each other The beat frequency is also called the AMPLITUDE MODULATED FREQUENCY (AMF). It is a modulated alternating current with a surge speed which is varied at will. The intensity of the beat current is the sum of the two currents The beat frequency may be constant or rhythmic/variable. Rhythmic means that the frequency swings continuously changing from a lower to a higher value The interferential current generators will have two circuits of different frequencies:

One circuit has a fixed frequency of 4000 Hz (this will provide a pulse duration of 125 us which is appropriate for sensory and motor nerve stimulator) Second circuit has varied frequency of 4001 to 4100 Hz (the higher frequencies will encounter less skin impedance and are therefore more comfortable)

Resultant beat frequency ranges from 1-100 beats per second

The second circuit may be set at a fixed or a variably changing frequency

Physiologic Effects

Depress action of the sensory nervous system Stimulates large diameter sensory nerve fibers Stimulates motor nerves Increases vasodilatation Alter the cell membrane permeability

Purpose/Effects

At 50 beats/sec and low amplitude relief of pain by stimulating large afferent neurons and interfering with ascending (lemniscal) transmission of pain impulses At 0-5 beats/sec and an intensity sufficient to cause a mm contraction relief of pain by stimulating endogenous opiod production or interfering with ascending (extralemniscal) transmission of pain impulses At 0-10 beats/se stimulates innervated mm At 30-50 beats/sec tetanic contraction of innervated mm; but not effective for mm strengthening

Indications: Relief of pain Stimulate mm contraction in an innervated mm to increase blood flow, cause relaxation and relieve urinary stress incontinence Contraindications and Precautions: same as unipolar technique

High Voltage Pulsed Galvanic Stimulation

High Voltage Pulsed Galvanic Stimulation Has an electromotive force of up to 500 volts (low voltage units do not exceed 150 volts) Bypass the impedance of skin allowing use of lower current amplitudes

Description Waveform (pulse) consists of paired, unidirectional impulses that rise rapidly and decay exponentially Phase duration at base of each member of a pair of 50100 us Phase duration not sufficient to stimulate denervated mm and to perform iontophoresis

Purpose/Effects relief of pain reduced mm guarding promote tissue healing improve blood flow and decrease edema through intermittent mm contraction delay disuses atrophy and mm re education through mm stimulation

Contraindications and Precautions: other modes of ES

same as for