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AdditionalTherapeuticUsesof Electricity
()Lecture8: AdditionalTherapeuticUsesofElectricity
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Woundmanagement Osteogenesis Edemareduction Peripheralcirculation Incontinence

ESforWoundManagement
Wound
abreakinthecontinuityofsofttissuecausedbyphysical, chemicalorbiologicalinsult Complications:chronicinflammation,infection,and scarring associatedwithotherimpairments,suchaspain, decreasedmobilityandmotorfunction

PhasesofWoundHealing Phase1
Inflammatoryphase(day1 6)
Initialvascularconstriction:decreaselocalblood flow,allowmoreefficientclotting Vasodilation:deliverchemicals,cells,nutrients andoxygentoinjuredtissue
Promotecapillarypermeability Chemotaxis:bodilycells,bacteria,andothersinglecell ormulticellularorganismsdirecttheirmovements accordingtocertainchemicalsintheenvironment Increasefibroblastandmacrophageactivity
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ES
asdirectintervention,oradjunctstootherwound management PatientsreferredtoPTforEStreatmentareusually:
Chronicwoundnotresponsivetoothertreatment:Neuropathic ulcer,pressureulcer Orneedtoacceleratehealingprocess

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PhasesofWoundHealing Phase2
Proliferativephase(day3 20)
Reepithelialization:regrowskinoverthewound
Toprovideaprotectivebarriertopreventfluidand electrolytelossandtodecreasetheriskofinfection

PhasesofWoundHealing Phase3
Remodelingphase(day9on)
Maturationphase Continuedfibroblasticandcollagenactivity Collagenundergoesbothsynthesisandlysis balancebetweenthesetwoprocessesdetermines theeventualamountofscarformation Thisphaseischaracterizedbyscarcontractionand mayalsoincludescarhypertrophy

Fibroblastsarriveandbegintoproducecollagen torebuildthesiteofinjury Neovascularization

Developmentofanewbloodsupplytotheinjuredarea Newvesselsareneededtosupplyoxygenandnutrients totheinjuredandhealingtissue
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RationalesForUsingESForWound Management
Skinbattery&currentofinjury Galvanotaxis Speeduphealingprocess Antimicrobialeffect

SkinBattery
Transepithelial potentialbetweenthedermisandepidermis Whentheskinisdamaged,thedifferenceinpotentialisbelievedto bethesourceofthecurrentofinjury Thiscurrentisatriggertowoundhealingandalsoassociateswith themoistwoundhealingprocess Ifwoundsarepermittedtodry ceasethecurrentofinjury UseEStoinfluencethecurrentofinjuryandthelateralelectricfield thatexistsinareasofskindisruption

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Galvanotaxis
Cellwithchargeattractedtoanelectricfield

SpeedUpHealingProcess
Augmentationofcollagensynthesisandproliferationof fibroblasts
Fibroblastsnormallymigrateintothehealingwound,especially duringtheproliferativephase ESincreasesDNAsynthesisandcollagensynthesis

Promoteangiogenesisandwoundmicroperfusion
EScouldstimulatecapillaryregrowthintothewound EnhancedmicrocirculationinchronicwoundinresponsetoES

Enhancingtherateofepithelialization
Fasterepithelialization
Evidenceshowedthatifwoundstreatedwithanode7days,orwith cathodeonthefirstdayandanodefortheremaining6days

Enhancingbloodflowtowounds
Enhancingbloodflowtowoundsbytheuseofelectrical stimulationappliednearthewound
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Antimicrobialeffect
Electricalstimulationhasbacteriostatic(inhibit growth)orbactericidal(killbacteria)effectson variouspathogenicorganismsthatarecommonly foundtoinfectwounds Electrodepolarityforantimicrobialeffects
CathodeforPseudomonasaeruginosa () BothanodeandcathodeforStaphylococcusaureus ()

ESForWoundManagement
Cleansewoundthoroughly,removedead tissuesandpetrolatumproducts Cover/fillwoundspacewithgauzepads soakedinsalineorhydrogel Placeanelectrodeonthegauzepacking,cover withdrygauze,holditwithbandagetape Dispersiveelectrodeusuallyproximaltothe wound
12 Source:Woundcareinformationnetwork,SUSSMANPHYSICALTHERAPYINC.

Electrodecompositionforantimicrobialeffects
Electrodesconsistingofsilverwireshowedsuperior effectswhencomparedwithstainlesssteel,platinum, orgoldwireelectrodes
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Microcurrent ES
Polarity&electrochemicalreaction
Cathode(negative):raisethepHtoalkalinityforming maybeused foritsbactericidaleffectorasanadjuncttodebridementbecauseof itssclerolytic ability(decreaseproteindensity)tosolubilizethrombi andnecrotictissue Anode(positive):lowerthepHtoacidityforming maybeusedfor itseffectofsclerosing tissueandcoagulatingbloodleakingfromsmall vessels mayalsoaugmentclosureofthewoundbyproducinga congealedscar

Microcurrent ESApplication
Thenegativeelectrodeispositionedinthewoundareafor thefirst3days;after3daysthepolarityisreversed Ifthewoundsizestopsdecreasing,thenreturnthe negativeelectrodetothewoundareafor3days Ingeneral,thesecondelectrodeisapproximatelythesame sizeastheactiveelectrodeandisplacedat15to30cm awayfromthewound

Ifinfectionwithorganisms,suchasEcoliandPseudomonas aeruginosa ()ispresent,thenegativeelectrodeshouldbe leftinthewoundareauntilthesignsofinfectionarenotevident. Thenegativeelectroderemainsinthewoundfor3daysafterthe infectionclears. IfthewoundisinfectedwithbacteriasuchasStaphylococcus aureus (),thepositivepolemaybeamore appropriatechoice
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RecommendedProtocol
Currentintensity<1mA Pulseduration:longpulsedurationorcontinuous uninterruptedcurrent Frequency:50 200Hzorcontinuous Waveform:monophasicdirectcurrentisbest,but biphasicdirectcurrentisacceptable Treatmentduration:2hoursfollowedbya4hour resttime Treatmentfrequency:2 3timesperday No.oftreatmentdays/week:5 7perweek
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HighVoltagePulseCurrent
Electrodeplacement
Generallyoneelectrodeoverthewoundandasecond electrode15to20cmawayovernormaltissue Thedispersiveelectrodewasusuallyplacedproximal andlargerthanactiveelectrode

Polarityofstimulation
Negligibleelectrochemicaleffects Effectofpolarity
Thenegativepoleretardsmicroorganismgrowth Thepositivepolefacilitatescellularmigration,particularityin theproliferationphaseofwoundhealing
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PolarityConsideration&Protocol
Selectionofpolarity
Usuallyinitiatedwiththecathodeastheactiveelectrode Afterseveraldaysoftreatmenttheelectrodepolarityis reversedtothepositivecharge Negativepolarityisusedifmicroorganismsarepresent continuetousenegativepolarityuntilthewoundis culturefreefor3days Positivepolarityisusedifthewoundisculturefreeoris usedafterthewoundisculturefreefor3days

ESForWoundHealing HighVoltage PulseCurrent

Recommendedprotocol
Frequency:30 130pps Amplitude:subthresholdtomusclecontraction
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ESForWoundHealing HighVoltage PulseCurrent

Signsofadverseeffects
Skinirritationortinglingundertheelectrodes Pain

ESForOsteogenesis
10%ofthe7.9millionannualfracturepatientsintheUnited Statesexperiencenonunionand/ordelayedunions Severalmethodshavebeenusedtopromotebonehealing
Electricalstimulation Lowintensitypulsedultrasound Electromagneticstimulation

Precautions
Transcerebralstimulation Stimulationovertheeyes Youngchildrenunderage3years

Contraindications
Presenceofmalignancy Activeosteomyelitis Topicalsubstancescontainingmetalions:povidoneiodine,zinc, silversulfadiazine,mercurochrome Electronicimplants
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StagesofBoneHealing
Inflammatorystage Repairstage Remodelingstage
Hematoma Cartilaginous callus Bonycallus Remodeling

1.Inflammatorystage
Hematomaformswithinthefracturesite(first fewhourstodays) Cleanupdeadtissues Callusformation Thisstagelasts2 4weeks,overlapswiththe nextstage

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2.Repairstage
Cartilaginouscallus
Painandswellingsubsideasthebonyfragmentsunitedby cartilaginoustissue Osteoclastsremovedeadbonefragments

3.Remodelingstage
Weakstrongbonmaterial Bonereturnstoitsoriginalshapeand structure Remodelingoftheboneoccursslowlyover monthstoyearsandishelpedbymechanical stress(i.e.weightbearing).

Hardcallus
Cartilagehardening fromeachendoffracturetowardthecenter

Thisstagelasts1 2months

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RationaleForUsingESFor Osteogenesis
Chemicalgradientswithinthebone arethesourceofbioelectric potentials Normalbonehaspiezoelectric properties
Highercellularactivity(epiphysial platearea)morenegative

Microcurrent ES
Polarityofstimulation
Anegativeelectrodewasplacedclosetobutdistaltothe fracturesite Apositiveelectrodewasplacedproximaltothe immobilizingdevice

Recommendedprotocol
Currentintensity:justperceptibletothepatient Pulseduration:ContinuousorpulsedDCwithlongest durationallowedontheunit(100 200msec) Frequency:lowestfrequencyallowedontheunit(5 10 pps) Treatmentduration:30minutes 1hour Treatmentfrequency:3 4timesperday
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Bonegenerateselectricalpotentials inresponsetomechanicalstress
Compression Negative Tension Positive

Thepolaritychangesafterdiaphysis fracture EScausesionicmigration

TENS
Ifthefracturesiteisenclosedinaplastercast,electrodes shouldbeplacedproximalanddistaltothecast,2or4 electrodesareused

TENSApplication

Ifthefracturesiteisfreeof casting,3basicpatternsare available

With2electrodes,oneplacedon eithersideofthefracturesite, about6inches(15cm)apart

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TENSApplication

With4electrodes,across pattern,about6inchesapart, withthecrossingpointdirectly overthefracturesite

TENSApplication

Ifthefracturesiteisfreeof casting.With2electrodes,a sandwichpattern,withthe fracturesitebetweenthetwo electrodes

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TENS
Recommendedprotocol Sideeffects
Frequency:thehighest Analgesiawasreportedby frequencyavailableonunit patientswhocomplainedofpain (120Hz) asasymptomofthenonunion Pulsedwidth:thewidestwidth (300s) Intensity:thelowestpossible, barelysensedbypatient Treatmentduration:1hour/ session Treatmentfrequency:4times /day
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ESForEdemaReduction
Rationale
Polaritymovesnegativelychargessubstancethat causededema Sensorylevelstimulation
Polarityofelectrode
Tousethepolarityofanelectricalstimulustorepelsimilarity chargedsubstancesfromtheedematousarea Becausebloodcellsandplasmaproteinscarryanegative charge anegativeelectrodeplacedoveranedematous areamayrepelthesenegativelychargedsubstancesfromthe areaofstimulation decreasingtheamountofedema throughafluidshift
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ESForEdemaReduction
Rationale 1
Sensorylevelectrical stimulustorepelsimilarity chargedsubstancesfromtheedematousarea
Bloodcellsandplasmaproteinscarryanegativecharge anegativeelectrodeplacedoveranedematousarea mayrepelthesenegativelychargedsubstancesfrom theareaofstimulation decreasingtheamountof edemathroughafluidshift

Rationale 2
Microcurrent stimulationofthelocal neurovascularcomponents
Amicroamp stimulationmaycausea vasoconstrictionandreducethepermeabilityof thecapillarywallstolimitthemigrationofplasma proteinsintotheinterstitialspaces Thiswouldretardtheaccumulationofplasma proteinsandtheassociatedfluiddynamicsofthe edemaexudate
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Rationale 3
Motorlevelstimulation
Electricallyinducedmusclecontractioncan effectivelyleadtoareductioninedemaby mobilizingtheedematomovefromtheinterstitial compartmenttothebloodvascularsystemand lymphaticsystem

ESForEdemaReduction HVPC
Applicationtechnique
Waterimmersionelectrodetechniqueismore effectivethanusingsurfaceelectrodes

Polarityofstimulation
Activeelectrodesisnegative

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HVPCRecommendedProtocol
Sensorylevelstimulation
Intensity:10%lessthanneededtoproduceavisiblemuscle contraction Frequency:high(120pps) Timeoftreatmentafterinjury:beginimmediatelyafterinjury Treatmentduration:30minutesevery4hours

ESForPeripheralCirculation
Introduction
Mostcommonlyappliedtopreventpostoperative thromboemboliccomplicationsandtoimprovecirculation Factorscontributingtotheformationofathrombosis
Changesinbloodflow Changesinbloodcoagulability Changesinthevesselwall

Motorlevelstimulation
Intensity:strong,comfortablemusclecontractions Frequency:35 50pps Ontime:5 10sec;Offtime:5 10sec Theparttobetreatedshouldbeelevated AROMmaybeencouragedatthesametimeifitisnotcontraindicated Treatmentduration:20 30minutes Treatmentfrequency:2 5timesperday
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RationaleforusingES
Electricalstimulationofthecalfmusclespreventedadecrease intherateofvenousbloodflowinthelegsduringsurgeryand thereforedecreasedthefrequencyofdeepvenousthrombosis Increasedcapillarybloodflowinthestimulatedmusclesresults fromacombinationofreflexivevasodilationandanincreasein capillarygrowthduringlongtermelectricalstimulation
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ESForPeripheralCirculation
InterferentialcurrentorRussianstimulation
Electrodeplacement:Oversensorynerves Recommendedprotocol
Currentintensity:maximumtoleratedtingling(sensorylevelstimulation) Frequency:50 200bps Cycleduration:20 100s Dutycycle:50%ifRussianstimulation Treatmentduration:20 60minutes

ESForIncontinence Indications(1)
Stressurinaryincontinence
Involuntarylossofurinewhentheintravesical(withinbladder) pressureexceedsthemaximumurethralclosurepressureinthe absenceofdetrusoractivity Smallamountsofurinearelostconcurrentwiththeincreased intraabdominalpressure

Urgeurinaryincontinence
Involuntarylossofurineassociatedwithanuninhibiteddetrusor contractionthatoverwhelmsthesphinctermechanism

Lowfrequencystimulators
Electrodeplacement:Overmotornervesofinnervatedmuscles Recommendedprotocol
Waveform:balancedasymmetricalbiphasicpulsedcurrent Currentintensity:motorresponse Frequency:30 100pps Treatmentduration:30 40minutes

Mixedurinaryincontinence Urinaryfrequencyorhesitancywithpelvicfloor dyssynergia

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ESForIncontinence Indications(2)
Fecalincontinencerelatedtopelvicfloor weakness Levator syndrome
Painintheregionofthecoccyx Painfulspasmsofthemusclesaroundtheanus withoutknowncause Althoughbowelmovementsmatnotbepainful, patientsoftenreportdisturbedbowelfunction, constipation,orfrequency

ClinicalApplication
Purpose
Tohelpthepatientidentifythepelvicfloormuscle location,provideproprioception,andassistthe contraction Toachieveautonomicdampeningofthesebladder contractionsbyaugmentingsympathetic dominance

Interstitialcystitis
Aconditionofoversensitivityofthebladder
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Electrodeselection:Whenpossible,an internalelectrodeispreferred
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RecommendedProtocols
Vaginal andanalplugstimulation:aanalorvaginalplugwithtwo embeddedringelectrodes Patientsposition:beginwiththepatientinanantigravityposition(ie, relaxedhooklyingorsidelyingwithoneortwopillowsunderthepelvisor betweenthelegs)andslowlyprogresstostanding Themostcomfortablecurrentsaredeliveredbycircularelectrodes,which areabletodispersecurrentoverlargesurfaceareas Frequency:5 50Hz
Ahigherfrequencyof50Hzismostamenabletoinnervatedmuscle it workswelltoteachmusclecontraction,proprioception,andawareness Alowerfrequencyof5 20Hzismostamenabletotreatdetrusorinstability andurgency

InterferentialCurrent
Pelvicfloorstimulation Electrode:externalelectrodes Patientsposition:asemireclined positionwiththehipsandknees flexedandsupported Electrodeplacement:bipolartechnique
Female:oneelectrodewasplacedunderischial tuberositywitha secondelectrodeovertheanteriorperineum,immediatelyinferiorto thesymphysis pubis Male:electrodesplacedoneachsideoftheglutealcleft,justanterior totheanus

Treatmentdurationandfrequency:2or3minutesofstimulation1 3 timesadayisagoodbeginning,graduallybuildingupto15minutes1 2 timesaday Afterthefirstfewsessions,whenpatienthasbeenabletoidentifythe contraction,askthepatienttocontractwiththecurrent,relaxingin between

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Currentintensity:50 80mA,maximumlimitofpatientcomfort Frequency:asweepfrequencyof10 50Hzorafixedfrequencyof 50Hz Treatmentduration:30minutes

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TENS
Purpose:
Tobemoreeffectiveinrelievingpelvicandperineal pain Tobeusefulintreatingdetrusorinstability

TENSParameters
Mode:conventionalsetting Currentintensity:sensorylevel Frequency:60 100Hz Pulsedduration:100 150s Treatmentduration:20 30minutes Treatmentfrequency:1 5timesaday

Electrodeplacement:Relatedacupuncturepointsare useful
Spleen6(Sp 6):3cmdirectlyabovethetipofthemedial malleolusontheposteriorborderofthetibia Spleen10(Sp 10):withkneeflexed,2cmabovethesuperior medialborderofthepatellaonthebulgeofthemedialportion ofquadricepsfemoris Largeintestine4(LI4):inthemiddleofthe2ndmetacarpal boneontheradialside Acrossedfashionoverthelowerabdomenorlumbarsacral areas
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