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ELECTROTHER APY

electrotherapeutic modalities

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electrotherapeutic modalities .. maping and simple explanation

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Page 1: electrotherapeutic modalities

ELECTROTHERAPY

Page 2: electrotherapeutic modalities

The choice of adequate modality is according to the structure to be treated, the pt. tolerance and the absence of contraindications.

We can use more than one modality to treat the same condition ( multi modal ttt)

Def.: use of electricity in the ttt of musculoskeletal disorders.

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Electrotherapeutic modalities:DC

Interrupted low freq.

DC

valve

Surged current

*The most common form of electrotherapy is pulsed or interrupted AC.

MF (monophasic) DF (diphasic) CP ( courte “short” period) LP ( long period)

Diadynamic current

TENSIFCSWD

Deep heating

Low freq. current

Medium freq. current

High freq. current

ULTRASONIC THERAPYLASERULTRAVIOLET

US WAVESLIGHT WAVESLIGHT WAVES

Electrical stimulation→ nerves + ms.Thermal,

Mechanical, Chemical and

biological effects

Thermal, Physical ,

Chemical and biological effects

Erythema production, Tanning, Epidermal

hyperplasia, Vitamin D synthesis

ACTNS

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TNS (Transcutaneous neuromuscular stimulators)

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DC

Interrupted low freq. current

valve

MF (monophasic) DF (diphasic) CP ( courte “short” period) LP ( long period)

Diadynamic current

TENSIFC

Low freq. current

Medium freq. current

Electrical stimulation→ nerves + ms.

AC

TNS(Transcutaneous neuromuscular stimulators)

Surged current

Denervated Ms.

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Galvanic (direct) current

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Galvanic currentIt is a direct Current used to stimulate muscle directly, without activation of the peripheral nerve “ surged current”.- Direct muscle stimulation requires pulse of long durations of at least 100 milliseconds, and more often uses even longer durations. appropriate electrical stimulation can cause a denervated muscle to contract•contraction of a denervated muscle may help limit edema and venous stasis within the muscle, and therefore delay muscle fiber degeneration and fibrosis•recovery time following denervation appears to be shortened with appropriate electrical stimulation

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Rheobase: is the minimum DC necessary to produce a contraction in Ms.Chronoxia: is the time in which a current double the rheobase produce a contraction. The Chronoxia in normal Ms. differ from 1/8000 – 1/20000 a second. In denervated Ms. The Chronoxia is increased 20 – 100 times the normal amount from the tenth day onwards. Duration

Str

eng

th o

f S

tim

ulu

s Minimal time

Utilization time

Chronaxia Rheobase

Time

Cu

rre

nt in

ten

sit

y

Threshold

Rapid rise Effective

slow rise Ineffective in innervated Ms. but effective in denervated Ms.

Threshold

Rate of rise of intensity Too slow rise in stimulus strength→ nerve accommodation occurs (i.e. rise in the threshold of stimulation of the tissues) → no response of the innervated ms. This propriety used to selectively stimulate the denervated ms.

nerve accommodation

nerve

Ms.

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Surged current(ramping): gradual increase the charge applied to the tissue hence increase the intensity of Ms. Contraction attained. This achieved by gradual increase in the amplitude or the pulse width of the pulse train. This allows for accommodation of the nervous tissue to pulse delivery. It is postulated that slow rising pulses of long duration selectively stimulate denervated Ms. As opposed to fast rising pulses of short duration that stimulate innervated Ms.

Surged rectangular surged triangular sow tooth

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• Galvanic current indications:• Electro diagnostic• ++ of paralyzed Ms. Of LMNL.• Peripheral nerve injury.• Bell’s palsy. • Iontophoresis.• Hysterical conditions.

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Diadynamic current

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Diadynamic current:Def.: sinusoidal direct low frequency current (50-100 Hz).Type of Diadynamic current:1- monophasic (MF):50Hz impulse & interruption 10m.sec.Effect: muscles stimulation ms. contraction. 2- Diphasic (DF): freq. 100HZ & non interruption. Effect: affect autonomic nervous system by lowering the sympa. Tone.3-Short “courte” periodes current (CP): sudden alternation between monophasic and diphasic>Used for: long term pain relief.4-Long periods current (LP): MF mixed with a second modulated MFUse: analgesic effect pt. feels pleasant sensation than that produced by CP. 5- Rhythmic Syncope (RS): This consists of 1.1 second MF followed by 0.9 second rest phase.

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Therapeutic effects and mechanism of action:1- analgesic: may be due to blocking of a particular area of the reflex (through nerve fibers).DF brief analgesic effect.CP long term pain reliefLP reduce pain “with pleasant sensation”. 2- hyperemic ( anti-edema): DF decrease sympathetic tone V.D increase blood supply increase metabolic rate in the tissues rapid reabsorption of edema decrease swelling rapid recovery.3- muscles stimulator: MF is motor stimulator, also RS and modulated MF (L.P) produce muscles contraction.

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Treatment strategy:- Current strength is gradually raised to the tolerance level

(pt. remain comfortable)- Duration : 2-12 min .. Not exceed 15min.- Therapy : 6 application ( EOD or daily). Sever cases up to 3

time /day- The interval between sessions should not > 48hs.- Even if the pathological symp. Disappear afer 2-3 sessions

add 2-3 sessions to stabilize the effect. - If after 6 sessions non improvement; interrupt for 1week and

recontinue.

Indication:

•Sport inj.(rapid effect) Sprain, Contusions, Dislocation. ms. And joints pain.• MSk problems & soft tissues inj.( OA – RA – back pain – neck

pain … etc.) • Neuralgia and neuritis.(trigeminal, brachial, sciatic, herpes

zoster neuralgia…etc)N.B.: Diadynamic c. can be used alone or with other modalities like ultrasound and microwaves.

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contraindications:Acute infection Various dermatological lesions.Metal implantation.Malignancies.

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Interferential therapy

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Interferential therapy: Def.: it is a form of electrotherapy

in which 2 medium freq. currents are used to produce low freq. effect. Principle: skin impedance

(resistance) is inversely proportional to the freq. of the current used. So the main problem associated with low freq. is the very high skin resistance which is the cause of pain during treatment. Resistance decreases if 2 medium freq. currents crossing the pt. tissue one of them is kept at constant freq. of 4000 Hz and the other change between 3900 – 4000 Hz.

So peak effect = diff. between the 2 = 100 Hz (low freq. current).

4000Hz3900Hz100Hz

The low freq. current effect is developed at The point where the 2 currents cross ( low freq. effect).

More comfortable than low freq. and more tolerable.

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physiological effect: and advantages

1- relief pain (80 – 100 Hz): local ↗ of the circulation. pumping effect of the ms. removal of waste productes. autonomic effect on the autonomic nerve. stimulation of large diameter nerve fibers which inhibit transmission of small diameter nociceptive traffic (by 80 – 100 Hz) “gate control”. stimulation of small fiber which will cause the release of enkephalin and endorphin at spinal level ( by 15 Hz).

2- Motor stimulation: ms. Contraction (1 – 100Hz )

o Turtches (<5 Hz)o Partial tetanic (5 – 20 Hz)o Tetanic ( 30 – 100 Hz)

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Stimulation of both voluntary and smooth ms. (but faradic stimulation only voluntary ms.) with little sensory stimulation more comfortable. contraction of deeply placed ms. E.g.:

• Lower abdominal ms.• Pelvic floor ms. In stress incontinence.• ms. of inner side of the thigh.

3 - Absorption of exudate ( 1 – 10 Hz)• Rhythmic ms. Contraction (pump)• and autonomic effect on the blood vessels absorption of exudate ↘ swelling.

4 - ↗ healing (up to 100 Hz): ↗ tissue healing & resolution of acute and chro. Inflammation.

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Factors affecting physiological effect of I.F.CI. Current intensity• Low sensory response (fine tingling), used in acute pain, swelling and ↗ circulation.• Medium strong tingling + ms. contraction. Used in ms. Srengthing & ms. Reeducation.• High painful stimulation(↗tingling + contraction + pain), used in chro. Pain.

II. Beat of frequency: • 1 – 10 Hz ↘ swelling.• 5 – 20 Hz motor stimulation.• 80 – 100 Hz pain relief.

III. Rhythmic or constant IV. Accuracy of electrode positioning.

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Indication of IFC:o Reduce inflammation & oedema (by Increased local blood flow ).o Muscle stimulation (ms. Reeducation and strengthing)o Pain relief.

Contra-indications:Acute inflammation or TBMalignancy.Metal implants.Pace makersSkin lesions.IntolerancePregnancy, menses (excessive bleeding) for IFC of lower abdomen.Over thrombo-phelibitis (release of thrombi)Febrile conditions.

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Dangers:Bare electrode touches the skin.Electrodes on the skin are too close allowing the short circuit.

Technique of application: Preparation of the pt. ᴥ comfortable ᴥ skin soaks with saline ᴥ skin lesions is insulated with pet. Jelly.

Preparation of the apparatus ᴥ electrodes connected to terminal ᴥ pads soaked with saline

Application of current: Positioning the electrodes so that the crossing points of the 2 currents is over or within the lesion. appropriate freq. to the indicated condition. current intensity is adjusted until the pt. feels mild tingling sensation. after few minutes accommodation may occurs and the intensity may be increased for about 15 minutes.

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T E N S

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TENS transcutaneous electrical nerve stimulationDef.: is the application of pulsed low freq. current of rectangular wave through

surface electrode on the skin surface over afferent nerve endings for stimulating the sensory component of the peripheral nerves to decrease pain.

Physical characters:o It is a sensory stimulator not ms. Contraction deviceo It is either monophasic or biphasic o It has different shapes: rectangular or spikeo The most effective shape is still unknown.o It is formed of pulses which has 0.2m.sec ( as duration < 10m.sec stimulate

sensory only not motor fibers.o Intensity 60 milli-ampears ( can be modified according to the propose response.

( as intensity from 30 – 150 milli-ampears stimulate sensory only not motor fibers.o Freq. low ( 10 – 100Hz) conventional TENS.

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Mechanisme of TENS: ( physiological effect just pain relief) a) According to gate control theory, pain which is transmitted by

small unmylinated fiber my be inhibited by stimulating thick mylinated fiber.

b) Electrical stimulation may ↗ release of endogenous morphine like substances: which has analgesic properties and so that the affect of TENS might be measurable by estimated of the level of opiate like substances as enkephalins & endorphins.

c) It is suggested that it can ↗ pain threshold.d) psychological (placebo) effect. Methods of application of TENS: Transcutaneous method:stimulation of the peripheral nerves by

application of the electrodes on the skin superficially. Percutaneous method: used as diagnostic to assess the possible

value of an implantable nervous system stimulator. Implantation method: applied by using a cuff electrodes of

various size which is placed around the affected peripheral nerve usually proximal to the area of injury.

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INDICATIONS of TENS:o Acute pain:• Musculoskeletal system:

Articular : arthritis non articular: strain of ligament muscles sprain. lumbar spondylosis.• Sport injuries: lig. Or ms. Sprain. shoulder contusion. • Neurological: Trigeminal neuralgia. Brachialgia sciatica post herpetic neuralgia• 1st stage of labour.

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INDICATIONS of TENS: …conto Chronic pain:• As rheumatoid arthritis, osteoarthritis.• LBP. Lumbar spondylosis.• Neuropathy or myofacial pain.

o Post-operative pain:• Including dental extraction, post-laminectomy or

abdominal injuries.o Cardiopulmonary problems:• ↗ pulmonary function test after thoracotomy.• ↘ pain of frozen shoulder.

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Electrodes: Made of carbon filled silicon. It require gel forApplication.If allergy use another) certain called Karaya-electrode “ skin friendly electrode”, or interrupt the period of stimulation with period of rest.In acute post operative incisional pain we use a disposable pre-sterilized electrodes. Technic of stimulation:The pt. should recognize the device and theelectrodes and the tingling sensation which canbe felt during the application and this sensationmust be strong and tolerable at the areaof stimulation.The freq. of the device range from 10 – 150 Hz.The electrodes are placed at the region of pain.

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Electrodes placement:By direct application to the skin.1) over painful area.2) in case of nerve root irritation which produce

radiating pain; one electrode is placed over its dermatomal distribution, the other electrode is placed over the side of the affected spinal segment root level.

3) In cases of nerve root without radiating pain ;one electrode ipsilateral and the other contralateral.

4) If the pain is muscular or bony origin the electrodes are placed over the myotomal or the sclerotomal distribution.

5) In peripheral nerve injuries or peripheral neuropathy the stimulation is at the site of the pain

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Electrodes placement: … cont6) In neurological injuries the loss of sensation in

the painful area, contralateral stimulation can be done.

7) In low back pain and cervical syndrome, bilateral stimulation of the painful area or the ipsilateral is effective.

8) If there is localized pain and no trigger point are involved place one electrode on the painful area and the other over the dermatomal distribution either on the opposite side of the corresponding level or distally according to the pain radiation.

9) During labour: ↗freq. 120 Hz. proximal electrode over T8. distal electrode over S1 2ed stage anterior abdomen.

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VERTIGO

Duration and freq. of treatment:• The session of the pt. is 30 – 60 min

about 2 – 4 times / day.• The periods of ttt must not be less

than 30 days at least.• Rarely pt. use the device 24hs but it

seems to be less effective.Side effect of TENS:o thalamic stimulation by TENS may

lead to vertigo, nausea, shortness of breath or nystagmus.

o Allergy to gel of electrode.

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CONTRAINDICATIONS of TENS:• Over the carotid sinus.• Corticosteroids are avoided because it suppress the

endogenous analgesic system. • In case of unknown pathology. For feer of mistaking pain

harm to the pt. • Pt. with cardiac pacemaker as TENS may interfere with it • Acute illness.• Fever > 38 c • Over pregnant uterus.• In case of malignancies