i

Handbook of
Practical Electrotherapy
 Handbook of
Practical Electrotherapy

Pushpal Kumar Mitra

Lecturer in Physiotherapy
NIOH, Kolkata

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Handbook of Practical Electrotherapy

© 2006, Pushpal Kumar Mitra
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system,
or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or
otherwise, without the prior written permission of the author and the publisher.

This book has been published in good faith that the material provided by author is original.
Every effort is made to ensure accuracy of material, but the publisher, printer and author will
not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters
are to be settled under Delhi jurisdiction only.
First Edition : 2006
ISBN 81-8061-620-7
Typeset at JPBMP typesetting unit
Printed at Gopsons Papers Ltd., A 14, Sector 60, Noida
 To
My dear departed
Mother, in her memory
 Preface
The scientific art of Physiotherapy has grown by leaps & bounds over the last few decades,
gaining credibility as an established drug-less discipline of modern medicine. The public at
large, especially in India, has become wary of the indiscriminate use of potentially harmful
drugs for even trivial complaints. More and more people are being drawn towards
physiotherapy, recognising it as an effective alternative to conventional drug based treatment.
Though the discipline of physiotherapy has been in practice for over half a century, physicians,
particularly in India, had been traditionally recommending physiotherapy, only as a
supplementary measure to the drug based regime of disease management.
Of late, due to wide coverage given by the media to such issues like the free availability
of over the counter drugs and the dangers of unmonitored use of such potentially harmful
agents, have created awareness among the population regarding the dangers of excessive
dependence on drugs. Physicians have of late begun to realize that physiotherapy can be
extremely effective for the treatment of many disorders, as a complementary force-multiplier
to their own efforts.
The role of physiotherapy in diverse areas of patient care, such as rheumatology,
orthopaedics, sports medicine, paediatrics, neonatology, geriatrics, neurology, gynaecology,
obstetrics, pulmonology, cardiology, etc. is now established beyond doubt and is accepted by
the medical fraternity worldwide. So much so, it has led to a change in the definition of
physiotherapy by the World Health Organisation.
This acceptance has led to a boom in physiotherapy education in India. Physiotherapy has
come of age as a viable career option, either as a self employed professional or as a part of
healthcare infrastructure, in India or abroad, drawing the best and the brightest students in
India. Major universities all over the nation are now offering physiotherapy as speciality
training, at undergraduate and postgraduate level.
In my capacity as a teacher and examiner spanning over two decades, I have had the
opportunity to interact closely with a wide spectrum of student community. The feedback
given by these students regarding problems that they face in pursuing a course curriculum
in Physiotherapy unanimously boils down to the lack of precise volumes that cover relevant
details of the subject, highlighting the applied aspect of the science in a format and language
that can be easily understood by them. This problem is easy to understand, since most of the
publications available on the subject are by foreign authors. Though very well researched and
descriptive, contents of these volumes are usually expressed in an English that is far beyond
the comprehension of the average Indian student, particularly if he/ she have had his/her
basic education in vernacular medium.
The genesis of this hand book on practical aspect of electrotherapy owes its origin to the
need among students for simple volumes, oriented to the practical application of the science,
viii Handbook of Practical Electrotherapy

with adequate text, backed up with plenty of illustrations, in easily understood format and
language. Happily enough, several young authors, involved with undergraduate teaching in
India, being actively encouraged by publishers with the vision, like the J.P.Brothers, are now
coming forward with excellent volumes that will go a long way to encourage many teachers
like me to do their bit for this noble cause. This is volume is a humble attempt to bridge the
gap between the text and the applied aspect of Electrotherapy. With no pretence of being a
magnum opus, it may provide an easy updater for the student or practitioner working in a
clinical setting.
The entire gamut of electrotherapeutics has been divided into three major sections, i.e.
therapeutic electrical stimulation, thermo therapy and actino therapy. Each section commences
with a review of the relevant biophysics. The applied aspects of the modalities considered
under each section have been listed under the headings of Points to Ponder,’ for quick review
of the essential information. This will be useful for bus stop revisions at exam time. The text
in this volume has been deliberately kept simple and short, with liberal use of illustrations to
project a word picture of the essentials in electrotherapy. Every effort has been made to make
the contents of this volume easy to understand and framed to stimulate the reader to try
using the techniques in a step-by-step manner during practice/clinical sessions. It is also
expected to help fledgling teachers of Physiotherapy, to impart basic training in electrotherapy,
with confidence, projecting the fundamentals firmly in front of their pupil, without too much
technical jargon, which often tends to confuse the teacher and the taught alike.
Among many unique features presented in this volume, I would like to highlight the sections
on precise dosing parameters for each modality. This can be an excellent guide for the beginner
in clinical practice. Each section concludes with a comprehensive chart that details all aspects
of practical application for individual modalities. Placement of electrodes, optimum dosage,
equipment settings, patient position, etc. has been detailed for each region of the body or for
specific clinical condition. Several advanced applications of electrotherapy, yet to be
mainstreamed in clinical practice in India, such as functional electrical stimulation or the
combination therapy, have been presented for the appraisal of the reader. The volume also
contains a section on frequently asked questions during the viva examinations, along with
short and to the point answers. The students can use this section as a means of complete
revision at exam time, since each modality has been explored separately through short question
and answers.
My effort has been directed towards de-mystifying the science and makes it user friendly
for the budding professionals in physiotherapy. I have made every effort to make the volume
as free of factual errors as possible. However, I realise that there is still a lot of scope for
improvement in this volume. I shall be indebted to the reader for any valuable input to make
the further editions more useful.

Pushpal Kumar Mitra

 Acknowledgements
This volume would not have seen the light of the day without active participation of my
students in this project. My students, past and present, have been the friend, philosopher and
guide in this maiden venture. Their feedback, advice and quality assessment, though not always
flattering, have been the prime mover behind this effort. In this context I would like to convey
my sincere thanks to Ms. Bani Laha, my erstwhile pupil and present assistant, for the
motivation, backup support and secretarial assistance. I would also like to put on record my
appreciation for Mr. Devidutt Pathak, Mr. Ravishankar, Ms. Richa Kashyap and Mr. Prosenjit
Patra and Mr. Sapan Kumar, all Internees of physiotherapy at NIOH, for literature review
proof reading and research, to make this volume as foolproof as possible. Special mention
must be made for Ms. Divya and Ms. Suravi, visiting internees from GNDU, Amritsar for
organising the photo shoots. Finally I wish to convey my appreciation and thanks to my
teachers, colleagues and patients for their inspiration.
 Contents
1. Review of Basic Concepts in Electricity 1
2. Introduction to Electrotherapy 10
3. Therapeutic Electrical Stimulation 15
4. Low Frequency Stimulation of Nerves and Muscles (NMES) 24
5. Getting Started with Low Frequency Electrical Stimulation 30
6. Pain Modulation — Transcutaneous Electrical Nerve Stimulation (TENS) 50
7. Advanced Applications of Low Frequency Electrical Stimulation 57
8. Medium Frequency Currents 65
9. Therapeutic Heat 76
10. Deep Heat Therapy 85
11. Therapeutic Ultrasound (US Therapy) 98
12. Therapeutic Cold 119
13. Therapeutic Light (Actinotherapy/Heliotherapy) 130
14. Frequently Asked Questions in Practical: Viva Examination 142

Index 149
 1
Review of Basic
Concepts in Electricity
Definition than a conductor. The nature of static charge
may be positive (+) or negative (–).
Electricity is a form of physical energy that
• The objects capable of loosing electrons
exists in nature due to excess or deficit of
develop positive charge.
electrons in any living or non-living object.
• The objects capable of accepting loose
In modern times, electricity is the lifeline
electrons develop negative charge.
of human civilisation. Our world is so
• Static electric charge tends to distribute
dependent on electrical energy, that failure in
uniformly over a spherical surface and
the power grid assumes proportions and concentrate on pointed surfaces of the
significance of a national disaster. charged objects (Fig. 1.1).
It will be wise to remember that the living • Like charges repel and opposite charges
cell also works on definite electrical principles attract each other (Fig. 1.2)
like a car battery. Electrical potentials are • Static electric charge creates a sphere of
generated across the membrane of a living influence around itself. This is known as
cell, which governs movement of essential an electrical field.
ions in and out of the cell. Such ionic move- • The direction of the line of forces is
ments control the physiology and therefore directed away from the positively-charged
the life of the cell. body and towards the negatively-charged
Physical principles of electricity remain the body.
same in either context. In order to understand • Static electricity does not mean its sta-
the effect of electrical energy on the living cell tionary. A bolt of lightening strikes the
it is important to review the fundamentals of earth when the static electric
electricity once again. • Charge generated in a body of cloud
Electrical energy exists in nature in two becomes too great for the cloud to hold,
forms—static electricity and electrical current. generating intense heat that creates the
thunderclap by overheating the air in the
Points to Ponder atmosphere.
• Static electricity is the charge that develops • An electrical current is the flow of electrons
in any object that has free electrons, other through a conductor, from a region of
2 Handbook of Practical Electrotherapy

Fig. 1.2: Behaviour of electrical fields—Opposite

Fig. 1.1: Static electricity & electrical field—Static charges attract each other, thus flow of electron takes
electric charge tends to spread over the surface of place from negatively-charged pole to the positively-
the charged objects. Concentrations of charge are charged pole, which is known as electric current. The
greater on any pointed area. Positively-charged direction of flow of the electric current by convention
objects have deficiency of electrons, hence try to is opposite to the direction of flow of electrons, i.e.
attract electrons. Negatively-charged objects have positive to negative pole
surplus electrons; hence try to give up the excess
electrons. This imbalance in electron content creates
a sphere of influence around the charged objects,
• The supply line has a phase, a neutral and
which is known as the electrical field an earth connection.
• The phase carries the current, the neutral
higher concentration to a zone of lower completes the circuit and the earth provi-
concentration. des the escape route for any electrons from
• By convention, the direction of flow of that may have escaped the circuit. A fuse
electrons is opposite to the direction of or circuit breaker is essential as a safety
flow of the current (Fig. 1.2) feature in any circuit to break the flow of
• The rate of flow of electrons is measured current in case of any over load.
in Amperes.
• The force that drives electrons through a INTRODUCTION TO BIOELECTRICITY
conductor is known as Electromotive Force AND ELECTROPHYSIOLOGY
(EMF), arises from the difference of
Definition
potential between two points in a conduc-
tor and is measured in Volts. Bioelectricity can be defined as the inherent
• The force opposing the flow of electrons electrical energy present in a living cell and
through a medium is known as resistance the manifestation of this electrical energy in
or impendence and is measured in Ohms. day-to-day functions of the cell is called
• The domestic electric supply is an Alter- electrophysiology.
nating Current (AC) having a sine wave Have you ever thought why the fire fly
at 50 Hz frequencies. glows in the dark? Or how can the electric eel
 Review of Basic Concepts in Electricity 3

kill its prey with a shock? Or for that matter tial. Such changes of electrical potentials are
why does the physician order an ECG for a greater and more frequent in sensitive cells
heart patient? like nerves or muscles.
All have one common answer—Bioelectri- For ease of understanding, here after all
city. references to cellular potentials, will be in
All living cells are like miniature batteries, context of a human nerve cell, since these cells
constantly charging and discharging as it goes has the highest excitability among all the cells
about living. All of the cell’s physiological in the body. The neuron is composed of four
functions revolve around its electrical status. basic parts: the soma or cell body, the axon,
A healthy cell is the one that can hold a normal presynaptic terminals and the dendrites
level of electrical charge and sustain a fixed (Fig. 1.3). The soma surrounds the nucleus.
potential difference between the cell and its The axon can be part of the spinal cord,
environment. Any change in this normal connect with muscle nerves or sensory nerves,
electrical charge can render the cell, like a or branch into small fibres. The presynaptic
battery—dead. terminals branch off from the axon and send
The mystery behind this electrical pheno- the action potential to nearby neurons. Dend-
menon is hidden in the composition of the cell. rites sense information from neighbouring
Nearly 90 per cent of a living cell is made up cells.
of water, in which are dissolved a number of
salts. Like the acid solution in a storage RESTING MEMBRANE POTENTIAL
battery, the dissolved salts in the cellular fluid
Definition
provide the ions, which give the cell its
requisite electrical charge. Throughout its life At rest, every living cell tries to maintain an
this electrical potential of the cell changes electrical equilibrium across its cell membrane
simultaneously with all life sustaining that allows it carry out common minimum
processes, always to regain its resting poten- physiological functions. The potential diffe-

Fig. 1.3: A typical nerve cell

4 Handbook of Practical Electrotherapy

Fig. 1.4: Resting membrane potential in a nerve cell—The relative concen-

tration of positively-charged ions like Na+ and K+ is greater outside the cell
membrane than the inside of the cell. The inside of the cell has a large number
of negatively-charged ions like Cl– etc. This makes the intracellular
environment negatively-charged and the extracellular environment positively-
charged. Hence -70 mV potential difference exists across the cell membrane
of a nerve cell at rest

rence thus existing across the cell membrane • The inside of the cell becomes progres-
of a resting cell is called resting membrane sively more negative as compared to the
potential. outside as the K+ ions gradually diffuse
out.
Points to Ponder • This creates a difference of potential across
the cell membrane, which is known as
• The cell membrane is selectively more
resting membrane potential, which is
permeable to K+ ions, as compared to Na+ –70 mV in case of a nerve cell and -90 mV
ions. for a muscle (Fig. 1.4)
• K+ ions can enter or leave the cell by • Due to passive diffusion, the cell cons-
diffusion while the Na+ ions cannot do so. tantly looses K+ ions and some Na+ ions
• At rest, K + ions and other negatively gain entry to maintain the electrical
charged protein ions are concentrated equilibrium.
inside the cell giving it a net negative charge • The cell again expels these Na+ ions and
and Na+ ions in the fluid outside giving it the lost K+ ion is reabsorbed through active
a net positive charge. transport mechanism of sodium-pota-
• In a living cell, the number of Na+ ions are ssium pump mechanism, at the expense of
far greater than K+ ions ATP.
 Review of Basic Concepts in Electricity 5

• The resting membrane potential creates an

electrical field that allows the cell to draw
essential elements and throwout or avoid
unwanted elements.
A cell with normal resting membrane potential
(-70 mV in case of nerves and -90 mV in case of
muscle cell) is regarded as healthy and one with
abnormal resting membrane is regarded as sick.

ACTION POTENTIAL (AP)

Definition Fig. 1.5: Action potential: An action potential is

generated when the resting membrane potential is
An action potential may be defined as the reversed due to any stimulus that upsets the resting
momentary electrical activity taking place in ionic balance of the cell
Stage 1. Resting membrane potential (RMP)-70 mV.
a cell, as a result of a stimulus, signifying a
Stage 2. A weak stimulus causes partial depolari-
sudden reversal of resting membrane poten- sation of the cell till it reaches critical threshold of
tial (Fig. 1.5).1 –55 mV.
A typical action potential has threshold Stage 3. Sudden depolarisation of the cell takes place,
with rapid reversal of the RMP.
potential, depolarisation, repolarization and
Stage 4. The cell is completely depolarised and
sometimes hyperpolarisation. An AP is an all reversal of the RMP takes place from -70 to +30 mV.
or none phenomenon. Once a nerve appro- This change is instantaneous creating a sharp spike
aches threshold potential, depolarisation potential.
occurs. Open channels for sodium to rush into Stage 5. The cell begins the process of recovery to
its RMP
the cell characterize depolarisation. An Stage 6. The momentum of repolarisation makes the
increase in the conductance of sodium is cell hyperpolarised.
observed and the sodium is driven to Nernst Stage 7, 8, 9, 10. The cell searches for the mean
potential. The membrane voltage peaks and RMP by losing or gaining ions as required through
the selectively permeable cell membrane
is repolarised by the outward movement of
potassium ions through open channels. An
risation of the cell creates a spike of electrical
action potential is often referred to as a spike
potential called the action potential.
because on time scales greater than milli-
second they appear as a vertical line. Points to Ponder
Any excitable cell like the nerve or muscle • All excitable cells try to retain normal
cannot maintain its resting membrane poten- resting membrane potential (Fig. 1.5,
tial indefinitely, since it’s bombarded conti- stage 1)
nuously with environmental stimuli, prog- • Any stimulus, mechanical or electrical,
ressively lowering its state of polarisation. makes the cell membrane more permeable
When such stimuli of sufficient intensity to Na+ ions.
hits the cell, a critical threshold of the potential • As the gates at the cell membrane open,
difference is crossed that leads to sudden Na+ ions rush into the cell, trying to change
depolarisation of the cell. The sudden depola- its polarity (Fig. 1.5, stage 2).
6 Handbook of Practical Electrotherapy

• If the stimulus is of small duration and and the phase of relative refraction (Fig. 1.5,
intensity, the degree of depolarisation is stage 5).
minimal and the cell soon regains its • The K+ channels remain open long enough
resting membrane potential by throwing to repolarise the cell to 10 to 20 mV below
out excess Na + ions to reduce its +ve the resting potential value of -70 mV. This
charge (Fig. 1.5, stage 8 to 10). process is called the phase of hyperpolari-
• An action potential is generated only when sation (Fig. 1.5, stage 6)
the intensity and the duration of the • K + channels soon close and through
stimulus is such that sufficient number of passive diffusion the cell returns to its
Na+ ions enter the cell to reduce the resting normal resting potential (Fig. 1.5, stage 7).
membrane potential to a critical threshold
PROPAGATION OF ACTION
value (-55 mV in case of nerve cell). Such
POTENTIAL (AP)
a stimulus is called liminal stimulus (Fig.
1.5, stage 3) Definition
• At this point, the voltage sensitive Na+ An action potential tends to move along the
channels open wide to allow a flood of Na+ body a nerve or a muscle cell, from its point
ions to enter the cell, completely reversing of origin, like a wave or ripple in a pool of
the resting membrane potential from-70 water. This is called the propagation of action
mV to +35 mV. This process is called potential.
depolarisation (Fig. 1.5, stage 2 to 4) An action potential generated in a nerve
• The inside of the cell becomes positively may propagate along the axon of the nerve in
charged as compared to the outside, as a either direction (Fig. 1.6).
result of flow of ions. In a motor nerve, propagation of action
• This state of reversal of potential lasts for potential takes place proximally towards the
a very short time (1msec) and the electrical CNS (anterior horn cells in the spinal cord)
changes are reflected as a sharp spike and distally towards the peripheral end organ
potential when seen through an oscillo- i.e. the muscle. Action potentials travelling
proximally towards the CNS are known as
scope. The spikes in an ECG are a common
antidromic conduction and those travelling
example of the action potential generated in the
distally towards the neuromuscular junction
heart muscle (Fig. 1.5, stage 4)
are known as orthodromic conduction.
• Once the depolarisation starts the cell does
In a sensory nerve, the orthodromic propa-
not respond to any stimulus till the cell has
gation of action potential takes place towards
repolarised to certain extent (Fig. 1.5, stage the sensory cortex and the antidromic conduc-
2 to 5). This state of the nerve is called tion takes place towards the peripheral
absolute refractory phase. sensory receptors on the skin.
• Sooner the peak of the action potential is The orthodromic propagation of action
reached the Na+ channels close and the K+ potential produces the desired effect in its
channels open wide, letting the cell loose target end organ where as the antidromic
K+ ions rapidly, making the trans-memb- conduction is believed to be blocked at the
rane potential progressively more nega- next node of Ranvier from its point of origin.
tive. This process is called repolarisation The character of conduction of an action
 Review of Basic Concepts in Electricity 7

Fig. 1.6: Propagation of action potential: An action potential (AP) generated in a non-myelinated nerve cell
spreads throughout the nerve cell membrane by cyclic local circuit depolarisation. The AP is conducted through
the axon to the motor neuron junction from where it is passed on to the muscle fibres, causing them to contract.
In a myelinated nerve the AP jumps from one node of Ranvier to the next, increasing the nerve conduction
velocity considerable. This is known as staltatory conduction

potential along a nerve varies according to the etc. The message carried by an action potential
type of the nerve being stimulated. depends on the rate of firing of the action
In a myelinated nerve, the action potential tends potentials. The higher the frequency of action
to jump from one node of ranvier to the next. potential firing, the more intense will be the
Jumping conduction of the action potential strength of muscle contraction or intensity of
from node to node makes it travel very fast sensation and the shorter the intervals
and such conduction is called staltatory between action potentials the weaker the
conduction. contraction or the sensation.
In a non-myelinated nerve, the action This is often referred to as frequency
potential travels by successive and progressive modulation (Deutsch and Deutsch, 1992).
depolarisation of the nerve membrane adjacent When generating action potentials artificially
to its point of origin. Such conduction is known by electrical stimulation, the desired effect
as local circuit conduction and is much slower depends on the frequency of the stimulus. At
as compared to that in a myelinated nerve. higher frequency the effects are limited to
Any action potential is a message. Messa- those nerves with a low threshold of sti-
ges are sent to contract desired muscles, to mulation, i.e. sensory nerves. For the motor
signal pain, or to maintain ideal temperature, nerve to be stimulated effectively, due to its
8 Handbook of Practical Electrotherapy

higher threshold, the frequency of stimulation • An action potential generated in a nerve

must be low and strong enough to produce may propagate along the axon of the nerve
muscle contraction.2 in either direction.
Every action potential is characterized by • Action potentials travelling proximally
a specific active one hundred millivolt signal towards the CNS are known as antidromic
that does not decrease in amplitude over time conduction and those travelling distally
(Kendal et al, 1991). Each of the fifteen sensory towards the neuromuscular junction are
receptors of the body sends its message known as orthodromic conduction
through a different path in the body. This is • The orthodromic propagation of action
how one sensory message is differentiated potential produces the desired effect in its
from the other. The action potentials gene- target end organ where as the antidromic
rated by motor nerves are similar in nature conduction is believed to be blocked at the
next node of Ranvier from its point of
and can spread its effect to the neighbouring
origin.
muscles throught he process of excitation.3
• The effect of an action potential depends
Points to Ponder on the rate of firing or the frequency of the
action potentials, the amplitude being
• Creation of an action potential at one
constant for a given type of nerve pro-
segment of the cell membrane triggers
ducing the action potential.
depolarisation of the neighbouring seg-
ments of the cell membrane. WHAT IS THE SIGNIFICANCE OF
• This wave of depolarisation moves along THIS BIOELECTRICAL DRAMA
the surface of the nerve or muscle cell, by TO THE PHYSIOTHERAPIST?
local circuit conduction, until the entire cell
• In the preceding chapter we have seen that
has been covered. The nature and rate of
the living cell generates and maintains
conduction of the action potential varies
detectable electrical potentials. This
according to the type of the tissue.
electrical potential existing in the living
• In non-myelinated nerve and muscle fibres
cell is subject to change, with every
the action potential spreads via successive
physiological activity of the cell. The
depolarisation of the neighbouring sites of cellular electrical potentials are so essential
the cell membrane in local circuit conduc- for the survival of the cell, that any
tion. The speed of such conduction is disturbance in the balance of electrical
inversely proportional to the diameter of potentials in the cellular environment can
the cell fibre. make the cell sick. Conversely, restoring
• In myelinated nerves, the ion exchange normal electrical potential of a sick cell can
takes place at the nodes of Ranvier, which cure the disorder of the cell. Since a living
are breaks in the myelin sheath of the cell, like the storage battery, is basically an
nerve. Conduction of an action potential electrical entity, it can be charged to an
takes place from one node of Ranvier to optimum potential by exposure to an
the next. This type of jumping conduction external electrical energy source, either
is called staltatory conduction. The speed directly or indirectly through an electrical
of such conduction is much faster than local field generated by electrostatic or electro-
circuit conduction. magnetic induction.
 Review of Basic Concepts in Electricity 9

• Understanding the electrical characteri- • Physiotherapist may use this information

stics of excitable cells like nerve and to assess, prognosticate and treat specific
muscle helps the physiotherapist disorders pertaining to the musculo-
• To identify external electrical energy skeletal system. EMG biofeedback is a
sources that can effectively influence the form of treatment that uses the electrical
electrophysiological function of these cells potentials generated by the skeletal
and derive a therapeutic benefit out if such muscles. The patient can be shown the
exposure. Different methods treatments pattern generated by maximal effort by a
for different malfunction in bodily tissues normal muscle, which acts as a target. The
have been devised based on the bio- patient is then asked to focus his effort in
electrical properties of the cell and their the effected muscles to reproduce the
pattern generated by the normal muscle.
response to various forms of electrical
Such feedback reinforces the activity in
energy. Thus the foundation of all electro-
affected muscles helping in re-education
therapy modalities is based on the bio-
of function, which is useful in treatment
electrical drama being enacted in the living
of upper motor neuron lesions.
cell throughout its lifetime.
• To summarise, for the physiotherapist, the
• Apart from the therapeutic application, knowledge of bioelectrical principals and
bioelectricity also serves an important its effects on the physiology of the living
diagnostic implication. Sensitive electrodes tissue serves as the corner stone for
are used to pick up the electrical potentials selection of appropriate electrotherapy
generated by the cell. These tiny electrical modality and application of the same for
potentials are amplified and modulated to different disorders. Further, this know-
produce discreet waveforms, which project ledge is also essential to under take various
reproducible information regarding the tests and interpret the results and protocols
electrical functioning of the tissue. The for electrodiagnosis. Therefore, an exhaus-
waveforms are then projected on to a tive knowledge of bioelectricity and
cathode ray tube for visual analysis. Any electrophysiology is the key to turn the
malfunction in the tissue is reflected in the physiotherapist from a technician to a fully
waveform generated by the tissue. For fledged clinician
example, ECG, EEG and EMG are bio-
electrical tests that provide relevant REFERENCES
information regarding the electrical func- 1. Alberts B, Bray D, Lewis J, Ra HM, Roberts K,
Watson JD. Molecular Biology of the Cell.
tioning of the heart, brain and the skeletal
Garland Publishing Inc: New York, 1983.
muscles respectively, indicating the state of 2. Walsh JC. Electrophysiology. In Electrophysical
health of these organs. Nerve conduction Agents in Physiotherapy: Therapeutic and
velocity (NCV) study indicates the rate of Diagnostic Use (Wadsworth H, Chanmugan
conduction in a nerve. Results of these tests, APP, Eds) Science Press: Marrickville, NSW
Australia, 1988.
when compared to normal values, may 3. Charmen RA. Bioelectricity and electrotherapy-
help in diagnosis of any disorder in these Towards a new paradigm? Part 1-4. Physio-
organs or tissues. therapy 1990;76(9,10,11):503-730.
10 Handbook of Practical Electrotherapy

2
Introduction to
Electrotherapy
Definition Benjamin Franklin, philosopher, scientist
and one of the authors of the Constitution of
Application of electrical energy to the living
United States of America was probably the
tissue for remedial purposes is known as
first person to deliberately apply electrical
electrotherapy.
charge to a paralysed limb, with shocking
Such therapeutic application of electrical
results. The experiment however had to be
energy can be done: prematurely discontinued due to extreme
• Directly, through amplitude or frequency reluctance on the part of the patient to be
modulation of electric current to stimulate subjected to such torture.
excitable tissues like nerves and muscles, Even today, most patients turn pale or
commonly known as low or medium even miraculously recover, whenever low
frequency stimulation. frequency electrical stimulation is discussed
• Indirectly, using the capacitance or induc- as a therapeutic option. I have often found
tance properties of living tissue, subjected many seasoned therapists to be reluctant to
to high frequency electrical field, to test the electrical stimulators on themselves,
generate heat in the tissues, commonly and choose to ignore an essential safety
known as short wave or microwave checklist, just because of its close association
diathermy. to an electric shock.
• By converting high frequency electric • The situation however reverses and the
current into high frequency sound energy, patient becomes readily compliant, if the
to produce mechanical micro-massage, same electrotherapy involves application
heat generation and protein synthesis, of high frequency current to generate heat,
commonly known as ultrasound therapy. as in SWD or ultrasound therapy.
The first-ever recorded attempt at appli- • Safety considerations in electrotherapy
cation of electrotherapy is credited to the
ELECTRICAL SAFETY
ancient Greek, who used live electric eel
placed in a shallow tub of water to soak the Dear reader, please pay close attention to the
feet in, as a treatment for gouty arthritis. following passage and really think about the
 Introduction to Electrotherapy 11

points to ponder, as this may save a life some mica/glass top) in an electrotherapy
day. Under the oath of Hippocrates, health department.
care professionals are debarred from, • Engage a qualified electrician to check
knowingly or unknowingly, harming their your electric supply lines periodically,
patients. This stricture holds good for the paying maximum attention to the affec-
physiotherapists, particularly when using a tivity of the earth line and proper calibra-
lethal energy source like electricity. Every tion of the mains fuse.
possible precaution must be taken to prevent • All electrotherapy equipments must be
accidental injury to the patient while applying isolated electrically from each other and
electrotherapy the patient, to minimize the risk of acci-
You must remember that electricity is a dents, signal interference and malfunction.
potentially lethal energy source that can kill
or injure the careless. Equipment Safety in
Safety in application and maintenance of the Electrotherapy Unit
all electrotherapy equipments should be given
Any machine has the freedom to malfunction
first priority, particularly if they are used in
and the electrotherapy equipments are no
close physical contact of the patient, with the
exception. Moreover since the nature of
body being arranged as a part of the circuit.
electrical energy is potentially lethal, its use
on living human beings calls for extreme
The Environment of the
caution.
Electrotherapy Unit
• Electrotherapy equipments are electronic
Electrical energy, in spite of its uses, is devices that usually operate on the domes-
potentially lethal in nature. tic AC power supply. Some of these
Safety-first should be the primary concern equipments may be battery operated.
behind the design of any electrotherapy unit. • As a safety feature, all electrotherapy
The common sense dictates that if you are equipments use earth free DC current. The
playing with a potentially lethal energy, your primary current is obtained from domestic
primary concern should be to avoid risks that AC current supply. A suitable voltage is
could endanger your and your patient’s life then obtained by subjecting the AC current
and well being. to a step down Trans former. From the
secondary coil of a step-down transformer,
Points to Ponder an earth free AC current is obtained. This
• The environment of the electrotherapy unit earth free AC current is then routed
must be dry and damp free, with insulated through a full wave rectification circuit to
flooring having vinyl tiles or linoleum. obtain an earth-free DC current (Fig. 2.1).
• The therapist and patient must use insu- • Earth-free current used in electrotherapy
lated footwear (rubber or plastic) in equipments eliminate the risk of earth
absence of insulated flooring. shock. It is therefore essential to periodi-
• Always use wooden plinths and insulated cally check the earth-free nature of the
equipment trolley (metal frame with sun secondary current supply in all electro-
12 Handbook of Practical Electrotherapy

• Always make a visual check before using

any electrotherapy equipment and test the
machines periodically on yourself. Any
defective equipment must be taken out of
circulation immediately and sent for
repair.
• The service engineer must certify repaired
equipments in writing, before being put to
use on patients. This will save you from
legal action in case of an accident involving
repaired equipment.
Fig. 2.1: Converting AC current to earth-free DC • Preventive maintenance includes yearly
current: Alternating current from the domestic outlet checkups by qualified service engineer.
is subjected to full wave rectification and smoothing • Do not handle equipments with wet
to obtain monophasic earth-free DC current which is hands.
utilised to operate electrotherapy equipments
Safe Application Procedure of
therapy equipments by a qualified techni- Electrotherapy Modalities
cian. This should be clearly understood that the
• Any electricity that leaks from the circuit electrotherapy modalities are applied on the
between the live and the neutral terminal surface of the skin. Hence, the energy derived
from the primary circuit is diverted to the from these modalities are have to travel
earth through the earth terminal. Hence a through the skin to the under lying tissues to
qualified electrician should check the produce the desired effects.
proper functioning of the earth terminal The skin is the largest organ in the body,
provided with the domestic supply outlet. covering the entire surface of the body, which
If the earth line is defective the equipment has largely a protective role to play. As such
body. the skin has five layers of cell, four of the top
layers being composed of dead cells and only
Points to Ponder the lower most layers having living cells. This
arrangement of cellular layers is useful in
• The electrotherapy equipments must be making the skin impervious to heat, cold,
stored in damp proof wooden cabinets. water, corrosive chemicals, friction and
• The electrotherapy equipments must have electrical charge. The electrical resistance
matched internal fuses. Fuses of less or offered by dry skin is in the region of 5000
larger calibre may damage the equipment. Ohms. For applying electrical stimulation, a
• All leads and cables must be checked large volume of electrical energy will be
frequently for any crack or damage. needed to over come this resistance and reach
Always store leads and cables in a loose the underlying muscles and nerves. The
coil and avoid trailing them on the floor, sensory receptors of the patient may not be
kinking or bending them. able to tolerate such high intensities of
 Introduction to Electrotherapy 13

electrical current. Hence, prior to application if the patient feels any unexpected sensa-
of electrical charge, in the form of electrical tion like too much heat, prickling or
stimulation to the body tissues, the skin burning.
resistance must be brought down to at least • Keep an alarm bell near the patient in case
1000 Ohms. This procedure of lowering the you are needed to be called.
skin resistance is applicable to any form of • In case of the very old or very young or
electrotherapy or electrodiagnosis that utilises mentally retarded patients, avoid the use
direct application/transducing of electrical of deep heat or prolonged cooling. The
charge to or from the body. It is not relevant reaction threshold of these patients may be
for other applications of electrotherapy like inappropriate and you may be informed
thermotherapy, insonation or actinotherapy. of any discomfort too late to prevent
damage.
Points to Ponder • In pregnant or menstruating patients
avoid exposure of the pelvic region to deep
• Ensure the body surface of the patient is dry
heat modalities like short wave or micro-
before giving high frequency current, parti-
wave diathermy. In case of a male avoid
cularly in humid conditions, because of the risk
exposure to testes.
of scald due to concentration of current over
• Do not give any electrotherapy over eyes
moist areas.
and heart.
• Moisten the part carefully before low or
• Always use protective goggles while
medium frequency current therapy, to applying any light modality like infrared,
lower the skin resistance or the patient is ultraviolet or laser.
likely to feel intense burning sensation. • Keep a detailed record of any adverse reaction,
• Make sure the patient does not have a pace like allergy or rash or burn that may occur
maker while entering an electrotherapy in spite of precautions and seek medical
section, because the electrical field gene- advice if the reaction is severe.
rated by the electrotherapy equipments are • Management of electrical accidents
likely to interfere with the function of the Accidents may still occur in spite of your
pace maker within a range of 3 meters. best efforts to avoid them. In case of an
• Switch off and remove any mobile phones unfortunate incident when someone suffers
and hearing aids, while applying high an electric shock follow the following points
frequency modalities. carefully.
• Warn the patient not to move unneces-
sarily or touch the equipment body while Points to Ponder
being treated. • Disconnect the mains supply to the
• Be careful not to keep any lead or cable in equipment.
contact with the body of the patient. • Disconnect the patient from the machine
• Explain to the patient in detail, the circuit.
expected reaction or sensation produced • Lay down the patient if in shock and turn
by a specific modality, before application. the head to one side if the patient is
• Stay close by while the patient is under unconscious; this will do to prevent the
going electrotherapy. You may be needed tongue from falling back (and so prevent
14 Handbook of Practical Electrotherapy

any blockade of the airways). To position • Do not leave the patient alone.
the tongue away from the windpipe, it • In case of a scald or burn, apply cold water
must be tied to the lower jaw with a to the site. Do not spill water on the
handkerchief, to prevent it from falling equipment.
over the entrance of the airway. Start • Prescribe a topical antibiotic cream like
cardiopulmonary resuscitation (CPR) if silver sulphadiazine (silverex) in case of
breathing has stopped. Send for medical blister formation.
assistance while you try to stabilize the • Keep your professional indemnity insu-
patient. rance paid up to date.
 3
Therapeutic
Electrical Stimulation
Definition Nature of Such stimulus may be mecha-
nical, like a sharp tap on the nerve or the
Electrical stimulation involves application of
tendon; chemical, like the discharge of
suitably modified electric current to stimulate
neurotransmitters taking place at the neuro-
excitable tissues like nerves and muscles, with
muscular junction or an electrical impulse.
the aim of producing physiological reactions
Once the depolarisation of theses cells reach
that have clear therapeutic benefits.
a critical level the chain reaction takes over
The application of electrical stimulation,
till an action potential is created. Since nerves
as an integral part of electrotherapy, has come
have a lower threshold they are stimulated
a long way since the times of Benjamin
faster than the muscles. The required intensity
Franklin.
of the stimulus is lower in the nerves than in
With the advent of computerized stimu-
the muscles (Fig. 3.1).
lators, with idiot proof features, it has now
become an effective modality in the arsenal
Points to Ponder
of the therapists, with carefully modulated
impulses that cause minimum irritation and • Intensity of each stimulus or pulse ampli-
discomfort to the patient, while getting maxi- tude must be strong enough to cause the
mum response from nerves and muscles. resting membrane potential to be lowered
However, to be able to use this therapeutic sufficiently to achieve the critical thres-
hardware, one must be well conversant with hold, which is the point of no return for
the characteristics of electrical stimulation, the nerve/muscle to depolarise comp-
necessary to initiate depolarisation in excit- letely. However, once the cell depolarises,
able tissues like nerves and muscles. repetition of the stimulus of same or
greater intensity will not provoke any
HOW DOES ELECTRIC response till the cell has re-polarized.
STIMULATION WORK? Nerve cells work on the principles of all
Nerves and muscles are excitable tissues that or none law.
respond to any sharp and sudden stimulus • The duration of each stimulus or pulse
that can cause depolarisation in these cells. duration must be long enough to produce
16 Handbook of Practical Electrotherapy

Fig. 3.1: Nature of electrical stimulus: Electrical Fig. 3.2: Types of electrical impulses: Types of electri-
stimulation is an artificial electrical stimulus of specific cal impulses commonly used in electrical stimulation
pulse duration, intensity and shape, applied to an are fast-rising or slow-rising in nature. In a fast-rising
excitable tissue to generate a response. It is first given impulse the intensity rises from zero to peak within a
at low intensity, which is then gradually increased till very short period of time. This rapid rise does not allow
the critical threshold of the excitable is crossed, to the nerve to be accommodated, causing depola-
produce a response in the target tissue, i.e. nerve or rization. Fast-rising impulses can be square, rectangu-
muscle lar or spike-shaped. Slow-rising impulses, as the name
suggests, rise from zero to peak intensity with
depolarisation of the cell membrane. In sufficient time lag which allows the nerves to be
case of nerve, pulse duration between accommodated to the changing electrical environ-
0.01 to 1 msec is adequate to produce a res- ment. Hence, with such slow-rising impulses, higher
intensity stimulus can be used to stimulate denervated
ponse but for a muscle this is too short a muscles, which have much higher threshold than the
duration. A muscle cell devoid of nerve nerves
supply needs 100 to 300 msec pulse dura-
tion to provoke a contraction. • A fast-rising impulse have square, rect-
• The rate of rise of the stimulating current angular or spike-shaped.
from zero to peak must be adequately • Slow-rising impulses are trapezoidal,
matched to the response threshold of the triangular or saw-tooth in shape. Slow-
target tissue to produce a satisfactory rising impulses are also called selective
response (Fig. 3.2) impulses. Frequency or rate of repetition
• To stimulate a nerve the rate of rise must of a stimulus is the third most important
be fast enough to prevent accommodation. parameter in the biophysics of a stimu-
Accommodation is the rapid adjustment lating current.
of the nerve to changing electrical environ- • Lesser the frequency of a stimulus the
ment to prevent depolarisation. greater will be its effect on nerves and
• To stimulate a muscle devoid of nerve muscles and vice versa.
supply a slow-rising current is most sui- • Frequency of a stimulating current is
table. inversely proportional to pulse duration.
• The rate of rise of a stimulus is usually • The greater the frequency, smaller the
reflected in pulse shape. pulse duration
 Therapeutic Electrical Stimulation 17

Fig. 3.3: Motor unit— A motor unit is the fundamental building block of
the neuromuscular complex. A motor unit consists of one motor nerve
cell, its axon and muscle fibres supplied by the axon filaments. Many
such motor units combine together to make an innervated muscle. The
response threshold of such a muscle is equal to that of the motor nerve
supplying it

• Motor nerve or a motor unit has a fre- RELATIONSHIP BETWEEN STRENGTH

quency threshold between 1 to 150 Hz AND DURATION OF AN ELECTRICAL
with optimum pulse duration of 0.01 to STIMULUS: THE SD CURVE
1 msec.
The SD curve, a graph in which the X-axis
refers to the intensity and the Y-axis refers to
WHAT IS A MOTOR UNIT?
the duration of the stimulus with which the
• A motor unit is composed of one neuron, nerve/muscle is stimulated, determines the
its axon, dendrites and the muscle fibres close relationship between the intensity and
supplied by the axon (Fig. 3.3). the duration of an impulse (Fig. 3.4).
• It forms the building block of the neuro- The nerve/muscle is first stimulated at the
muscular complex. The entire motor unit longest duration, i.e. 300 msec and the intensity
shares the response threshold of the motor required in mAmp/mVolts to produce the minimal
neuron. Sensory nerves have a response perceptible contraction is recorded. This is known
threshold up to 4000 Hz, with very small as the rheobase value. The duration is then
pulse duration, because their response progressively lowered to 100, 30, 10, 3, 1, 0.3,
threshold is much lower than motor 0.1, 0.03, 0.01 ms and the minimum intensity
nerves. needed to produce a response is recorded. The
• Muscle tissue, without a nerve supply; values of intensity are then plotted against
have a very high response threshold respective pulse durations on a standard graph
requiring a large amount of current to be paper. The resultant plotting is known as the
stimulated. It needs a pulse frequency SD curve. The first recording of the SD curve
from 1 to 3 Hz, with optimum pulse dura- should be done at least three weeks after the
tion of 100 to 300 msec. suspected nerve injury. A series of recordings are
18 Handbook of Practical Electrotherapy

then taken, preferably on the same graph

paper, at an interval of one week each. The
shifting of the curve will indicate the status of
nerve recovery (Fig. 3.5).

Points to Ponder

• Rheobase is the intensity of current

required to produce a minimal perceptible
response in a nerve/muscle with a stimu-
lus of infinite duration, i.e. 300 msec.
• Chronaxie is the shortest pulse duration
required to produce a minimal perceptible
Fig. 3.4: Strength duration curve indicates the rela- response in a muscle, at twice the intensity
tionship between the intensity/strength of an electrical of Rheobase. Normal chronaxie for inner-
stimulus and the duration of the stimulating electrical
vated muscle is less than 1 msec.
impulse
• Electrical response of any excitable tissue, like • A strength-duration curve (SD curve) is
an innervated muscle, depends on the intensity, plotted to determine whether a muscle is
the duration and the rate of rise of the stimulus innervated, denervated or partially dener-
applied to it. vated/innervated.
• While plotting a SD curve the target muscle or
nerve is stimulated with a rectangular interrupted
galvanic stimulus with pulse duration of 300 msec. TYPES OF THERAPEUTIC CURRENT
• The intensity required to produce a minimum
perceptible response at maximum duration is Therapeutic currents can broadly categorised
recorded, which is known as the rheobase. as stimulating and ionising currents. Stimu-
• The duration is then progressively shortened to
lating currents are classified on the basis of
100, 30, 10, 3, 1, 0.3, 0.1, 0.03, 0.01 msec respec-
tively. Frequency, duration and shape of the stimu-
• The intensity required eliciting response at each lating impulse. They may be either low
of these pulse durations are recorded. frequency or medium frequency currents,
• The pulse duration that is needed to elicit a which have stimulating effects on nerves and
response at intensity double the rheobase is
known as the chronaxie.
muscles. The ionising currents usually have
• In the above example, at the maximum pulse a high frequency range and have mostly
duration of 300 msec, the minimum intensity heating effects on the body tissues.
required is 5 mv.
• This remains constant even though the pulse Low Frequency Currents
duration is progressively shortened up to the pulse
duration of 1 msec. Electrical current impulses having pulse
• The required intensity then rises sharply as the
frequency between 1 and 250 Hz, used for
pulse duration is further shortened to 3, 0.1, 0.03
and 0.01 msec. Such SD curve is typical of a stimulation of nerve or muscles, are known
normally innervated muscle as low frequency currents (Fig. 3.6).
 Therapeutic Electrical Stimulation 19

Fig. 3.5: Relationship between strength and duration

of an electrical stimulus to predict improvement or
worsening of nerve supply to a muscle
Fig. 3.6: Low frequency current forms
• Strength duration curve, when plotted repeatedly,
Low frequency currents are basically of two types,
at intervals of one week, can give a picture of
interrupted galvanic current and faradic current.
progressive innervations or denervations taking
• Monophasic rectangular pulses, with durations
place in a muscle.
ranging from 10.01 to 300 msec are called inter-
• The graph at extreme right shows a picture of
rupted galvanic current.
complete denervation in the muscle, with the
• Ultrashort duration interrupted galvanic impulses,
required intensity rising sharply as the pulse
shaped like a spike, available in trains of impulses,
duration is shortened beyond 100 msec.
are known as faradic type current.
• When the graph is plotted subsequently after
• Such train of impulses can be modulated to
some time, the required intensity rises sharply till
produce a wave-like pattern, is known as surged
up to 10 msec and then levels off creating a kink
faradic current.
at 10 msec.
• Biphasic impulses, with a shallow positive phase
• Thereafter the required intensity remains same
and a sharp negative phase is called pure faradic
as the pulse duration is progressively shortened
current. Such currents are produced by the Smart-
to 3 msec.
Bristow coil and are not used nowadays
• This kink is indicative of partial innervations of the
muscle. Subsequent graph plotted at an appro-
priate interval indicates normal nerve supply. Subtypes of Low Frequency
• In case of progressive denervation the kink shifts Stimulating Currents
towards the right upper corner of the graph, till a
full deneravtion pattern emerges. In case of a. Interrupted galvanic current Interrupted
progressive innervations, the kink shifts towards galvanic current is a monophasic direct or
the lower left hand corner of the graph, till a normal galvanic current, broken at preset intervals
pattern emerges. and allowed to flow for a preset pulse
• Thus the SD curve can be used to predict the rate duration with a frequency between 1 and
and the potential for recovery of muscle function,
6 Hz, and a pulse duration between 1 and
as a convenient tool of electrodiagnosis for the
physiotherapist. 300 msec. These are also known as long
• Site of lesion extent of denervation not detected duration currents, specifically used for
by SD curve stimulation of de-nervated muscles or
20 Handbook of Practical Electrotherapy

motor point detection in innervated

muscles.
b. Faradic type of current Faradic type of
current is very short duration monophasic
interrupted galvanic current, with fre-
quency between 50 and 100 Hz and Pulse
duration between 0.01 and 1 msec. These
are also known as short duration current,
specifically used as surged faradic current
for stimulation of innervated muscles.
c. Pure faradic current Pure faradic current is
a biphasic current with a sharp negative
spike of 1 msec, followed by a gentle
positive trough of 4 msec; with a frequency
of 50 Hz. Traditionally it was produced by
the Smart-Bristow coil, though not used
any more. Fig. 3.7: Current forms used in TENS:
d. Transcutaneous electrical nerve stimulation • Conventional TENS current consists of biphasic
(TENS) Transcutaneous electrical stimu- very short duration impulses at very high
frequency, with intensity just at the level of sensory
lation uses ultrashort duration (50 to 300 threshold. This type of TENS is called HI-TENS,
micro second) impulses at a frequency of 1 used for relief of acute pain.
to 300 Hz, used mainly for relief of pain • Selectively TENS may also be applied through
through stimulation of sensory nerves. The acupuncture points, with longer duration impulses
at low frequency, with high intensity almost to the
impulses may be asymmetrical biphasic or
level of pain threshold. Such TENS is called LO-
monophasic (Fig. 3.7). TENS, used for relief of chronic pain.
e. Iontophoresis Continuous direct current, • Burst mode TENS combines the characteristics
used at low voltage and intensity, with the of both HI and LO TENS, using train of impulses
aim of transferring therapeutically useful of HI-TENS repeated at a preset discrete interval
ions, through the skin or mucous memb-
are available in two-pole or four-pole format
rane to the body.
(Fig. 3.8).
MEDIUM FREQUENCY CURRENT
Subtypes of Interferential Currents
These types of currents are commonly called a. Two-pole medium frequency current
interferential currents and are in the frequency (2000-4000 Hz)
range of 2000 to 4000 Hz. These types of 1. Russian current (2000 Hz)
currents have a strong sensory effect and are 2. Medium frequency surge current
used for stimulation of deep muscle through (4000 Hz)
an interference pattern producing low fre- b. Four-pole medium frequency/interference
quency stimulation at a very high intensity, current (4000-4100 Hz)
bypassing the sensory barrier of the skin. Such 1. Classical interferential current
treatment modality is broadly referred to as 2. Isoplaner vector current
interferential therapy. The interferential currents 3. Dipole vector current
 Therapeutic Electrical Stimulation 21

c. Microwave diathermy (Frequency 1-10

GHz, wavelength 3-300 cm).

Points to Ponder
• Stimulating currents are those that can
generate response in excitable tissues like
nerves and muscles.
• Low frequency and medium frequency
currents are capable of generating such
response in nerves and muscles. This is
because the pulse duration in low fre-
quency and medium frequency currents
are large enough to cause depolarisation
Fig. 3.8: Current forms used in medium frequency sti- in excitable tissues.
mulation or IFT: • High frequency currents cannot generate
• Medium frequency currents produce significantly
such response because their pulse duration
less irritation than low frequency currents and
therefore can be used at much higher intensities, is too small. They are used primarily for
with deeper effect. heating tissues. Energy from high fre-
• Most commonly two independent medium quency current is transferred to the tissue
frequency currents are used, at frequencies slight through molecular agitation as heat.
out of phase.
• Nerves are more sensitive than muscles.
• Such current when crossed with each other’s field
produces a beat frequency deep within the body Nerves need smaller pulse duration than
tissue. the muscle to produce a response.
• The beat frequency thus achieved has all features
and effects similar to low frequency stimulation. PRODUCTION OF LOW FREQUENCY
STIMULATING CURRENT
HIGH FREQUENCY CURRENTS Basic circuit used to produce stimulating
These are used mainly for deep heating and do current is based on the multivibrator circuit,
not have any direct stimulating effect on which can interrupt a smooth monophasic DC
nerves or muscle due to extremely high current to produce interrupted galvanic
current. Most modern electrical stimulators
frequency in the range of 10,000 Hz to 3 MHz.
use a dual circuit with separated +ve and –ve
With proportionately small pulse duration,
terminals colored red and black respectively.
that does not cause depolarisation but creates
The equipment also offers interrupted galva-
oscillation of ions and molecules of the cell
nic current with pulse durations of 300, 100,
releasing energy as heat.
30, 10, 3, 1, 0.3, 0.1, 0.03 and 0.01 msec
available through a rotary step selector, as
Subtypes of High Frequency Currents
well as faradic type of current with adjustable
a. Long wave (Frequency 1 MHz, wave- surge duration and interval, through indi-
length 3 Km) vidual rotary selectors. The intensity controls
b. Short wave (Frequency 27.12 MHz, wave- are separate for either type of current
length 11.3 m) (Fig. 3.9).
22 Handbook of Practical Electrotherapy

alternating current, used in surged faradic

or asymmetrical alternating current, used in
high voltage galvanic stimulation.
• Polyphasic pulses Biphasic current produc-
ing three or more phases in a single phase,
used in Russian or interferential current.

MODULATION OF STIMULATING
CURRENTS
Fig. 3.9: Production of stimulating currents using a Modulation of a stimulating current is the
multivibrator circuit: A multivibrator circuit is an
oscillating circuit that is used to break smooth changes in the characteristics of the stimu-
monophasic DC current into discrete impulses of lating current, which occurs at a preset rate
different pre-selected pulse durations with different and limit, to avoid accommodation of nerves
pre-selected repetition rates during stimulation.
Nerves have the ability to rapidly adapt
WAVE PATTERNS OF STIMULATING to any changed electrical environment. This
CURRENTS makes a stimulating electrical impulse
The shape, polarity and the arrangement of ineffective, if applied for a long duration. As
the electrical impulse used in therapeutic such, the type of the impulses are altered or
stimulation is critical to the response it modulated automatically by present gene-
produces and is called its wave pattern. ration equipments, to suit the response thre-
Response of excitable tissue to the sti- shold of a nerve and the clinical result desired.
mulating current varies according to the Different forms of therapeutic stimulating low
shape of the stimulating current. Specific frequency currents are listed below along with
types of current impulses are needed to their usual application in therapy.
produce desired response in specific type of
tissues. Points to Ponder
• Continuous direct current Smooth unvary-
Points to Ponder
ing flow of electrons, used in Ionto-
• Monophasic pulses Unidirectional flow of phoresis.
electrons, interrupted at preset duration • Interrupted direct/galvanic current Sharp
and repetition rate, producing square, interruption of current flow at preset
rectangular, trapezoidal, triangular, used intervals after a preset duration of flow,
in Interrupted Galvanic Current or spike used in stimulation of denervated muscle.
shaped pulses used in Faradic Type of • Surged faradic current Wave-like gradual
Current. increase and decrease over a preset
• Biphasic pulses Bidirectional flow of duration and interval, used in stimulation
electrons, with one half of the cycle in of innervated muscles.
+ direction and the other in – direction of • Ramped current Sloping rise in intensity
the isoelectric line, producing symmetrical to a preset peak, within preset pulse
 Therapeutic Electrical Stimulation 23

duration, followed by a gradual or sudden • Anatomically, it is defined as the point

drop to zero, may be used in TENS, FES where the motor nerve enters an inner-
etc. vated muscle.
• When the nerve supply has been dest-
THE MOTOR POINT
royed, the motor point is located slightly
The motor point is that point on the surface distal to its original spot, towards the
of the body, where if applied, electrical insertion of the muscle.
stimulation can produce maximum response • A motor point is usually found on a
in the underlying muscle. muscle, at the junction of the proximal
Once the type of current has been selected 1/3rd and the distal 2/3rd of the belly or
it is important to identify the most suitable
the fleshy part of the muscle.
spot on the body, to apply it. The skin over
• To trace a motor point, it’s most convenient
entire muscle does not have equal sensitivity.
to use interrupted galvanic current, at
The electrical stimulation should be applied
pulse duration of 1 msec in case of inner-
through only those spots that produce
vated muscles and 100 msec in case of
maximum response with minimum intensity
deneravted muscles.
of current, i.e. the motor point (Fig. 3.10).
• Once the skin has been prepared and the
Points to Ponder electrodes have been positioned in appro-
• Electrophysiologically, the motor point can priate surface location over a given
be defined as the area of greatest excita- muscle, the intensity of the stimulus
bility on the skin overlying any superficial should be increased just enough to elicit a
muscle that can produce maximum muscle minimal perceptible twitch contraction in
contraction with minimum amount of the muscle. The active electrode is moved
current. over the approximate area of the motor
point till the maximum response for a
given stimulus is observed. This is the
motor point, which should be marked with
indelible pencil for future reference.
• Tracing of a motor point is essential for:
1. Plotting of a SD curve of a muscle.
2. Giving interrupted galvanic stimula-
tion to denervated muscles.
3. Locating the general area for electrode
placement for surged faradic stimula-
tion of innervated muscles.
Fig. 3.10: Motor point:
• Anatomically, the motor point may be defined as The main advantage of stimulating a
the spot where the motor nerve axon enters the muscle through its motor point is that, the
muscle. current intensity required to produce muscle
• Electrophysiologically, it may be defined as the
contraction is minimum, compared to any
spot on the skin surface over the muscle belly,
where strongest muscle twitch can be obtained other area on the muscle belly, thus causing
with minimum current intensity mild sensory irritation.
24 Handbook of Practical Electrotherapy

4
Low Frequency Stimulation of
Nerves and Muscles (NMES)
INTRODUCTION acute and chronic pain, because its effec-
tive and cheap, without any of the adverse
Electrical stimulation has been widely used
side effects of the pain killing drugs.
for many years for a variety of therapeutic
purpose on different types of excitable tissues.
HOW DOES NMES WORK IN BUILDING
• In case of normal skeletal muscles, electric
MUSCLE STRENGTH AND PREVENTING
stimulation provides artificial exercise by
DISUSE ATROPHY?
producing sustained contraction, parti-
cularly when the muscle is unable to • High-intensity electrical stimulation is a
contract actively due to pain, weakness or proven way to maintain size, and even
restrictions like a plaster cast. For getting function in muscles, which may tempo-
best results, the muscle must be contracted rarily be rendered inactive due to injury
voluntarily, along with electrical stimu- or immobilisation.
lation. The idea may sound a little shocking, but
• In case of denervated muscles, electric a number of scientific studies have confirmed
stimulation is used to slow down the that the right type of electrical stimulation can
process of disuse atrophy and shorten the keep muscles relatively sound, even when
recovery time. Apart from gaining strength they are not being stimulated by the nervous
or maintaining the physiological proper- system or engaging in any real activity.1 In one
ties in the muscle, neuromuscular electrical of the earliest published studies on the effects
stimulation (NMES) also helps to acce- of electrical stimulation, on the maintenance
lerate blood supply and drainage of of size and strength in immobilised muscles,
metabolic wastes from the muscles researchers electrically stimulated the quad-
through pumping action it induces during riceps and hamstrings muscles in the leg of
muscle contractions. Such pumping action an athlete daily, who was immobilised in a
helps relieve swelling of soft tissue, reduce lower-extremity cast for 3 weeks, because of
muscle spasm and hypertonus. Grade-II medial-collateral and anterior-
• Electric stimulation is also widely used on cruciate ligament sprains in his knee. On the
the sensory nerves for management of day the cast was removed, the girth of the
 Low Frequency Stimulation of Nerves and Muscles (NMES) 25

athlete’s thigh had actually increased, sugges- “alpha motor neurons”. These nerve cells
ting that hypertrophy had occurred in the originate in the spinal cord and have
target muscles, instead of the usual immobi- relatively thin branches, which run out to
lisation—associated atrophy. In addition, muscle cells, which can stimulate muscle
single-leg, vertical-leap height was 92% as fibres to become active. As exercise
great in the immobilised leg following cast continues and more force production by
removal, compared with the uninjured leg, muscles is required, increasingly larger
and the athlete was able to immediately diameter alpha motor neurons become
return to competition.2 active. This order of activation from
Research has shown that NMES is effective smaller to larger motor-nerve cells has
in preventing decreases in muscle strength, been termed the ‘size principle’ of muscle-
muscle size, and even the oxygen-consump- cell recruitment.4
tion capabilities of thigh muscles after knee The size of the alpha motor neuron is closely
immobilisation. related to the type of muscle cell it innervates.
There is a fair amount of scientific evidence • Slow-oxidative (Type-I) muscle fibres are
that NMES can enhance functional perform- usually recruited first, by the small alpha
ance in a number of different strength-related motoneurons, whereas fast-glycolytic
tasks, in skeletal muscles and produce effects (Type-II) muscle cells are ordinarily much
similar to those associated with physical more difficult to recruit and generally
training? depend on the biggest alpha motor neu-
• One theory is simply that NMES produces rons. This helps to explain why someone
high-intensity muscle contractions which who is exhausted during prolonged
are similar to those occurring during endurance exercise, will suddenly feel
standard, low-repetetion, high-resistance capable of further effort, if he/she actually
strength training, and that as a result forces himself/herself to exercise much
muscles respond to NMES in ways which more intensely. In such cases, non-re-
are similar to the adaptations which occur cruited, non-fatigued, fast-glycolytic
during normal training. NMES imposes muscle cells can be brought into the action,
specific patterns of muscle recruitment and providing a big boost to exercise tolerance.
a particular “metabolic solicitation” which During NEMS of muscles, the order of
forces muscle cells to respond in a signi- muscle-fibre recruitment is often reversed,
ficant way.1 with the fast-glycolytic muscle fibres stimu-
However, there may be other factors at lated first rather than last and the slow-
work. oxidative muscle fibres recruited later.
• It is known, for example, that NMES Because Type-II muscle fibres have a higher
produces what is called a “reversal of specific force than Type-I muscle cells,
voluntary recruitment order.” At the selective augmentation of Type-II fibres
beginning of many volitional sporting through strong electrical stimulation may
activities, the central nervous system actually increase the overall strength of a
ordinarily first activates the smallest muscle or group of muscles.
26 Handbook of Practical Electrotherapy

Understandably, there has been a keen strength, isokinetic strength, or even the
interest in whether NMES might work for appearances of the subjects, compared with
healthy athletes or average person. The early the placebotreatments.
work of Y. Kots in the former Soviet Union
suggested that in certain cases NMES could Why such disappointing results?
be significantly more effective than exercise In order for muscles to improve their strength,
training itself in strengthening the muscles of they must be stimulated beyond a critical
elite athletes.3 If Kots’ findings were valid, threshold. This threshold probably needs to
athletes could improve their power while be as high as 60% of max-voluntary-contrac-
sleeping, simply by placing the right electro- tion strength in case of well-trained athletes
des over the key muscles involved in their and 30% in case of sedentary persons.6 In
sport! addition, NEMS should be utilised at the
Subsequently, devices for electrical sti- minimum threshold of at least 60% of max-
mulation have been marketed to athletes and voluntary-contraction strength. 7 Unfortu-
the general public, with the devices claiming nately, the over-the-counter device tested in
that they can improve muscle strength; this Wisconsin study produced a force equal
decrease body weight and body fat, and to less than 20% of max-voluntary contraction.
upgrade muscle firmness and overall tone. Importantly, too, the over-the-counter mach-
Sales of the NMES contraptions appear to be ine produced current frequencies of 90 to 151
red-hot, with a large number of people buying pulses per second; whereas 50 to 75 pulses are
the concept that they can build rock-hard considered optimal (overly high frequencies
buttocks and flat stomach while watching TV may induce too-early muscle fatigue). In
or relaxing at home. addition, the ‘on-off ratio” (the ratio of time
Recent, well-controlled scientific research stimulated to recovery time) was only 1:3.5,
carried out at the University of Wisconsin, even though about 1:5 is considered optimal
scientists assigned 27 college-age volunteers because considerable recovery is needed
into either a NMES group (16 subjects) or a between bouts of electrical stimulation to
control group (11 individuals). The NMES allow muscle cells to overcome fatigue.
group were stimulated three times a week,
following manufacturer’s recommendations, HOW DOES TRANSCUTANEOUS
while the control group underwent concur- ELECTRICAL NERVE STIMULATION
rent placebostimulation sessions.4 The mus- RELIEVE PAIN?
cles stimulated included the biceps femoris, TENS is a method of electrical stimulation,
quadriceps femoris, biceps brachii, triceps which provides a degree of relief symptomatic
brachii, and abdominals (rectus abdominis pain by specifically exciting sensory nerves.
and obliques). It can be used in several different ways, each
The study showed that NMES had no being best suited to different mechanisms of
significant effect on body weight, body pain production. Extent of pain relief would
fatness, fat weight, lean body weight, arm be in the region of 60%+ for acute pains and
girths, waist girths, thigh girths, isometric 40%+ for more chronic pains.
 Low Frequency Stimulation of Nerves and Muscles (NMES) 27

The technique is non-invasive and has few so doing; activate specific natural pain relief
side effects when compared with drug mechanisms. There are two primary relief
therapy. The most common complaint is an mechanisms that can be activated: the spinal
allergic type skin reaction (about 2% of gate control mechanism and the endogenous
patients) and this is almost always due to the opiate system.
material of the electrodes, the conductive gel Pain relief by means of the spinal gate
or the tape employed to hold the electrodes mechanism involves excitation of the A-beta
in place. sensory fibres, and by doing so, reduces the
The current intensity in the range of 0 to transmission of the noxious stimulus from the
80 mA is used, though some machines may ‘c’ fibres, through the spinal cord and hence on
provide outputs up to 100 mA, which is easily to the higher centres. The A-beta fibres appear
tolerated by the patient. to appreciate being stimulated at a relatively
The machine delivers ‘pulses’ of electrical high rate (in the order of 90-130 Hz or pps).
energy, and the rate of delivery of these pulses To activate the indigenous opiate mecha-
(the pulse frequency) will normally be nisms, the A-delta fibres must be stimulated.
variable from about 1 or 2 pulses per second These neurons respond preferentially to a
(pps) up to 200 or 250 pps. In addition to the much lower rate of stimulation (in the order
stimulation rate, the duration (or width) of of 2 - 5 Hz), which will, and provide pain relief
by causing the release of an endogenous
each pulse may be varied from about 40 to
opiate (encephalin) in the brain, which will
250 microseconds (A microsecond is a
reduce the feeling of pain.
millionth of a second).
The reason that such short duration pulses Points to Ponder
can be used to achieve these effects is that the
targets are the sensory nerves that tend to Therapeutic electric stimulation is used to:
a. Reduce pain—using T.E.N.S, causing
have relatively low thresholds, i.e. they are
• Activation of the spinal gate control
quite easy to excite and that they will respond
mechanism of pain modulation as per
to a rapid change of electrical state. There is
Malzack and Wall.
generally no need to apply a prolonged pulse
• Release of indigenous opiates of the
in order to force the nerve to depolarise,
body at pain receptors of the brain.
therefore stimulation for less than a milli-
b. Reduce muscle spasm—using faradic stimu-
second is sufficient.
lation, by
The pulses delivered tend to be asym-
• inducing muscle fatigue, through
metrical biphasic modified square wave
titanic contraction for several minutes,
pulses. The biphasic nature of the pulse means
produced by continuous faradic
that there is usually no net DC component, current stimulation.
thus minimising any skin reactions due to the • pumping of muscles, increasing the
build up of electrolytes under the electrodes. metabolic turnover, temperature, blood
circulation and drainage of metabolic
Mechanism of Action of TENS
waste, through cyclic contraction and
This type of stimulation excites different relaxation, produced by surged faradic
elements of the sensory nerve system, and by current stimulation.
28 Handbook of Practical Electrotherapy

c. Increase or maintain joint range of motion— electrical stimulation and in some conditions
using surged faradic stimulation, some- its application is strictly contraindicated.
times under tension, causing:
• stretching of tightened soft tissue Points to Ponder
around a stiff joint, caused due to weak
• Do not apply electrical stimulation over -
muscle action.
• release spastic muscle by induced • Healing fractures—may lead to dis-
fatigue or by reciprocal inhibition. placement of fractured bone ends.
• reduction of pain inhibition, to permit However, if the fracture is stabilized
muscle contraction and allow joint internally or in a plaster cast, stimu-
movement. lation may be applied through win-
d. Re-education of muscle action—using surged dows cut into the cast, to prevent disuse
faradic stimulation, by actively assisting atrophy of muscles.
muscle action to complete a movement. • Recent haemorrhages—may lead to
• providing visual and proprioceptive further bleeding.
feedback to the brain, to re-educate for- • Malignant tumours—may lead to spread
gotten pattern of movement. of cancer cells.
• improving co-ordination of voluntary • Acute infective focus/carbuncle/cellulites—
movements. may lead to spread of infection to the
e. Prevent disuse atrophy—using surged blood stream.
faradic stimulation to exercise a muscle, • Deep vein thrombosis—may lead to
with intact nerve and blood supply, but embolism of clot.
unable to contract due to inhibition or • Superficial metal implants, as in ORIF of
immobilisation. This can be done even if a superficial bones—may cause concen-
muscle is enclosed in plaster cast. tration of charge and cause burn of the
Using interrupted galvanic stimulation neighbouring tissue.
to give contractions to a denervated • Muscle of pharynx or voice box—may
muscle, to maintain its physiological pro- lead to problem in swallowing, cause
perties, retard disuse atrophy and promote choking or impair speech.
early repair of the damaged nerve. • Pregnant uterus—may cause sponta-
f. Reduce swelling of extremities—using surged neous abortion.
faradic current under compression and • Electrical stimulation is absolutely prohi-
elevation. bited in patients with demand type
g. Promote repair of soft tissue/wound—by pacemakers or diseases of hearts muscles
increasing supply of blood carrying O2 like myocardial infarction.
and nutrients, produced by pumping • Be careful while giving electrical stimu-
action in muscles due to surged faradic lation over:
stimulation. • Loss of superficial skin sensation—sti-
mulation may cause burn or itching of
WHEN NOT TO USE ELECTRICAL
the skin due to overdose, which the
STIMULATION? patient will not be able to tell you. In
Though it’s a versatile modality, certain such cases, look for strength of muscle
precautions must be taken while applying contraction to guide you. It’s useless to
 Low Frequency Stimulation of Nerves and Muscles (NMES) 29

apply TENS for relief of pain, in a case under pressure, keeping the limb in
of sensory loss, like in diabetic neuro- elevation.
pathy or any other sensory nerve
involvement, since the sensory path- REFERENCES
ways are not working and no relief of 1. Muscle electric stimulation in sports medicine.
pain will be obtained. Rev Med Liege 2001;56(5):391-95.
• Massive swelling—may lead to break- 2. High intensity electric stimulation—Effect on
down of skin, which is devitalised due thigh musculature during immobilisation for
knee sprain. A case report physical therapy
to poor blood circulation. This is parti- 1987;67(2):219-22.
cularly important in chronic oedema 3. Neuromuscular electric stimulation—An over-
following radical mastectomy or chro- view and its application in the treatment of
nic circulatory failure of lower limbs in sports injuries. Sports Medicine 1992;13(5):
varicose veins or burger’s disease. 320-36.
4. Effects of electric stimulation on body compo-
Always use effleurage massage to sition, muscle strength, and physical appear-
reduce the superficial oedema sub- ance. Journal of Strength and Conditioning
stantially before applying faradism Research 2002;16(2):165-72.
30 Handbook of Practical Electrotherapy

5
Getting Started with Low
Frequency Electrical
Stimulation
Know your stimulator, because it is very easy • For routine work, low frequency stimu-
for a fresh graduate to be lost in the hype, lators offering surged faradic and inter-
created by the equipment manufacturers; rupted galvanic current are used.
keen to sell their equipments in a cutthroat • All modern low frequency stimulators use
market. Most often people end up buying a basic circuit to produce interrupted
equipments with useless features for a galvanic current, with a wide range of
ridiculous price. To avoid such pitfalls, here pulse duration and frequency modulation.
are some tips on how to select the right machine The latest models have microprocessor for
for your need. accuracy of the pulse and frequency
modulation
Points to Ponder • Modern low frequency electrical stimu-
lators are marketed in two basic models,
• Electrical stimulators are used for stimu- therapeutic and diagnostic.
lation of excitable tissues like nerves and • Therapeutic model is cheaper than diag-
muscles, for therapeutic benefits. nostic model, but it does not have full
• Depending upon the nature of application, range of pulse durations of IG current and
an electrical stimulator may be called a digital or analog meter to show the
electrical muscle stimulator (EMS), neuro- intensity of the current. These two para-
muscular stimulator (NMS), TENS (for meters are essential to plot SD curve. My
pain control), functional electrical sti- suggestion would be to buy the diagnostic
mulator (FES), high voltage galvanic model because it gives the equipment a
stimulator or interferential therapy unit, wide range of clinical application.
though its basic function remains same, i.e. • A diagnostic stimulator must have sepa-
to apply electric charge to excitable tissues rate colour coded output for interrupted
of the body, through neural pathways. galvanic and faradic type current. The
 Getting Started with Low Frequency Electrical Stimulation 31

display must be clearly and accurately

printed under each control knob and
output terminals.
3. The switches and knobs must not have
any extra play and be of good quality.
The leads and cables must have ade-
quate conductors, insulation and be
pliable. The electrodes must have no
rough edges. Good quality accessories
and exteriors with careful finish may
indicate reasonable quality of the inner
Fig. 5.1: A diagnostic electrical stimulator. The set of
controls on the top row are for interrupted galvanic
components.
current. On the extreme left is a voltmeter indicating 4. Always check the make, model, and
the intensity of the stimulating current (this being a serial number is printed at the rear
constant current stimulator). To its right are the control plate of the equipment casing.
knobs for pulse duration, pulse repetition rate and
5. Check the fuse type, calibration and the
current intensity respectively. To the extreme right are
LED indicators and two output terminals for galvanic site of the fuse socket. Unusual fuses
current. The controls on the bottom row are dedicated and awkward location of fuse sockets
for faradic current. From left to right are the main switch may leave you needlessly dependant
with integrated pilot lamp, toggle switch to determine on the service engineer.
the sensitivity of the voltmeter (30/120 volts), control
knobs for surge duration, surge interval and intensity
6. Always test the machine on your self
respectively. On the extreme right are LED indicators before the decision to buy it, looking
and two outlets for faradic current for quality of the output current regard-
ing smoothness and consistency, at
pulse durations for IG current should be each duration setting and surge dura-
in the range of 0.01, 0.03, 0.1, 0.3, 1, 3, 10, tion. Any sharpness and burning
30, 100, 300 ms as well as continuous DC sensation felt, means poor quality of
current. The faradic circuit should offer modulation of the stimulating current
both continuous and surged currents with and automatic disqualification of the
separate controls to modulate surge equipment.
duration and intensity (Fig. 5.1). 7. Shop extensively for the best deal. Ask
• While selecting the stimulator it is impor- for the trade price as well as the MRP
tant to pay close attention to the following from the supplier. For equipments
ten points: made in India, negotiate directly with
1. Always opt for a model with fibre or the Manufacturer. Manufacturers often
powder coated metal body shell, to quote a price with the dealer commis-
minimize the risk of body shock. Check sion discounted.
the body for signs of crack or rust. 8. Remember that small scale local manu-
2. The face plate of the equipment must facturers can often give you custom
be made of polypropylene sheet or designed equipment, with maximum
other non-conductive materials. The number of useful features at a reason-
32 Handbook of Practical Electrotherapy

able cost, rather than established Points to Ponder

manufacturers, because their overhead
• Read the operating manual carefully to
cost is much less.
familiarize you with new equipment.
9. For imported equipments, contact the
Perform a visual check in case of old
main importer rather than sub-dealers,
equipments.
because the importers can give you a
• All electrotherapy equipment has two
better deal, as well as, provide quality
functional components, the machine
spares and service, due to their tie-up
circuit and the patient circuit.
with the foreign principals. Insist on
• After checking the leads and mains cable
complete installation and training at
for breaks or cuts, connect two carbon
the cost of the supplier.
rubber electrodes of 5 sq cm size, with red
10. After sales service is the most impor-
and black leads each, to the output
tant consideration for any equipment
terminal of the IG/Faradic current. The red
purchased. Most equipments carry one-
lead should be connected to the + terminal
year warranty period. Negotiate for
and the black-lead to the –terminal.
post-warranty annual maintenance
• Connect the equipment to the domestic
contract, before concluding the deal for
three pin wall socket, turn all knobs to
purchase. The supplier should prefer-
zero, and keep the electrodes side by side
ably have a local service centre manned
on a wooden surface away from each other
by qualified service engineer and off
and switch on the power switch of the
the shelf spares should be available.
equipment. See the pilot lamp is glowing.
The response time in any case should
This confirms the OK working of the
not be more than 48 hours. Always
machine circuit. Switch off the equipment
withhold 50% of the AMC amount till
from the power switch.
the completion of the contract period.
• Wet your left hand and place it on the
Renew the contract only on getting
electrodes so that part of the hand connects
satisfactory service. Approach the
with each of the electrodes, while the
consumer forum for redressal in case
electrodes do not touch each other. This
of any default by the supplier.
way your left hand becomes a part of the
patient circuit. Make sure that your right
MACHINE PREPARATIONS
hand is dry. Select 100 ms duration of IG
Electrical stimulators are compact electronic at one pulse per second or middle level
devices that can be operated with 220 volts surge duration through the selectors on the
domestic AC electric supply. Some stimulators equipment. Turn on the equipment power
have dual mode of operation, i.e. they can and slowly increase the intensity till you
work with mains, as well as, 9 volts battery feel electric impulses flow through your
power supply. Before commencing the treat- hand. Twitch contraction will be produced
ment the therapist must be familiar with the in case of IG current and a titanic contrac-
controls and test the apparatus on him/her. tion will be felt in case of faradic current.
This is essential to avoid any nasty surprises • Please let the current flow for one minute
for the patient during treatment. and ensure the current out put flows in
 Getting Started with Low Frequency Electrical Stimulation 33

uniform pulses and cause no burning • In case of upper limb stimulation, place the
sensation, then turn the intensity to zero patient in high sitting on a wooden chair
and switch off the equipment. with the limb resting in front of the patient
• Test the machine on yourself, preferably on a wooden plinth.
in front of the patient. It will not only • In case of lower limbs and back, place the
patient on supine/prone on a wooden
confirm the OK status of the equipment,
plinth.
but also will also give confidence to the • Expose the part to be treated and cover the
patient to undertake the treatment. rest of the body with a sheet.
• Therapeutic electrical stimulation is
PATIENT PREPARATIONS
usually applied transcutaneous or through
Low frequency electrical stimulation is the skin, to the nerves and muscles
potentially painful procedure and can adver- underneath. Skin resistance can be a major
sely affect the compliance of the patient. This problem in application of electrical sti-
is particularly important with young children mulation
• Dry skin has a resistance of 5000 ohms,
and nervous patients. Start with an expla-
since the epidermis is made up of five
nation to the patient as to why is it important layers of dead cells soaked in oily seba-
for him/her to undergo the procedure and ceous fluid, all of which resist flow of
what are the nature and intensity of sensation electric current.
he/she is likely to feel. If the patient is still • High skin resistance will need a large
apprehensive you may do the equipment intensity of electric charge to reach the
testing on yourself in front of the patient. This tissues below, which may be very painful
is likely to remove any lingering apprehension to the patient.
in the mind of the patient. • Preparation of the skin over the area to be
stimulated must be done to lower the skin
resistance to approx 1000 ohms.
Points to Ponder • The skin should be washed with soap/
• Counselling the patient before the treat- savlon to remove oil and dirt, rubbed
ment session is essential. vigorously with moist lint to remove dead
skin cells and lower the skin resistance and
• Question the patient to rule out any abso-
then soaked in saline to provide ions that
lute contraindication and identify any will help in carrying the current to the
precaution that you must take. Assess the subcutaneous layers.
feasibility of electrical stimulation yourself • If there is a break in the skin, sterile
even if it has already been prescribed. petroleum jelly should be applied over the
• Explain to the patient why it is necessary broken portion to avoid concentration of
to give stimulation and type of sensation the electric charge.
that will be felt during the treatment, best
SELECTION AND PREPARATION OF
described as tapping/tingling/ant bite etc.
STIMULATING ELECTRODES
• The treatment should be carried out in an
area with optimum privacy, having good Points to Ponder
tangential light, which will make it easy • Nature of stimulating electrodes: Electro-
for you to see contraction of muscles. des used for therapeutic stimulation are
34 Handbook of Practical Electrotherapy

strips of conductive material of sizes and • The covering of lint/sponge should be

shapes may vary from discs to rectangular soaked in tap water and squeezed to
or square plates depending on the site of remove excess water. The conductive plate
placement and type of use. is then introduced in to the layer of moist
• Types of stimulating electrodes (Fig. 5.2): lint or sponge, which helps to absorb
– May be shaped as pads or discs or pin corrosive ions produced by electrolysis
points. due to passage of electric current through
– Made of conducting material such as the electrodes.
lead, steel, zinc or carbonised rubber. • Polarities and types of electrode place-
Sizes range from pin-point, 1 sq cm to ment: The stimulating electrodes must
10 sq cm discs or pads. have two polarities, + and - to complete
• To avoid direct contact of the metal on the the circuit, so that pulse of electrical
skin the metallic conductive material current may flow between them. Any
should be covered by at least 8 layers of excitable tissue interposed between the
absorbent lint or a 1/2 cm thick envelope two polarities will then be affected by the
of sponge. electrical stimulus.
1. Monopolar placement—Two electrodes
of different sizes are needed to com-
plete the patient circuit, usually during
stimulation through the motor point.
The larger one of the two is called the
passive electrode and the smaller one
is called the active electrode. The
difference in size between passive and
active electrode must be 3:1.
2. Bipolar placement—Sometimes two
electrodes of same size may be used,
usually while applying surged faradic
Fig. 5.2: Different types of electrodes used in low stimulation to a group of muscles
frequency electrical stimulation:
• At the top is a disc electrode mounted on a
(Fig. 5.3, Plate 1).
penholder. 3. Colour coding—The active electrode is
• Below that, clock-wise from the top left are connected to the + terminal colour
stainless steel ball electrode, point electrode, disc coded red and the passive electrode to
electrode, steel plate electrodes and black carbon
the – terminal colour coded black.
rubber plate electrodes of different sizes.
• The ball, point and disc electrodes are used for 4. Shape of electrodes—In monopolar
detecting and stimulating motor points of muscles stimulation the passive electrode is
of different sizes. usually a carbon rubber pad and the
• The steel electrodes must always be covered with active electrode is a metal disc or point,
cotton and lint layer and must be soaked in water
before use. Rubber electrode can be applied attached to a pen holder. In Bipolar
directly to the skin over a thin film of electrode stimulation of muscle groups, two pads
gel. of equal sizes may be used.
 Getting Started with Low Frequency Electrical Stimulation 35

ferably over the proximal attachment of a

muscle or muscle group being stimulated. For
example, to stimulate the wrist and finger
flexor muscles, the passive electrode should
be placed over the medial epicondyle of
humerus, covering the common flexor origin.
If such a spot is not easy to reach in other
muscles, + electrode may be placed on the
point where the motor nerve supplying the
target muscle is most superficial or at the
spinal root level of the motor nerve e.g.
passive electrode may be placed over the
Fig. 5.4: Top—Vaginal electrode; Bottom—Rectal lumbosacral junction to stimulate the muscles
electrode: These are specialized electrodes used for supplied by the sciatic nerve. If the above
stimulation of the muscles of the vaginal and anal three options are not convenient, the
sphincters. Surged faradic current or two pole medium + electrode may be placed at any spot on the
frequency current may used for such stimulation body, close to the site of stimulation, e.g. for
stimulation of facial muscles, the most
Special Type of Electrodes appropriate location of the passive electrode
Specific areas like the vaginal and the anal is underneath the neck of the patient, in
supine position. The active electrode, co-
sphincter muscles may need to be stimulated
mmonly having the negative polarity, is used
in case of bladder and bowel incontinence.
to deliver the electrical charge to the excitable
Special types of electrodes that incorporate
tissues, preferably through the motor point,
both positive and the negative polarities in
since maximum stimulation can be obtained
one cylindrical body is used for this purpose
with minimum current intensity can be
(Fig. 5.4). obtained. However in case of a denervated
muscle the motor point may not be at the
THUMB RULES FOR ELECTRODE
original location and may have shifted
PLACEMENT proximally on the muscle belly.
In low frequency stimulation, the electrical When stimulating a muscle or a group of
impulses are applied from the surface, muscles, the active electrode should be placed
through the skin, to the nerves and muscles at the junction of proximal 1/3rd and the
underneath. Optimum effect of electrical distal 2/3 of the fleshy belly of the muscle.
stimulation can only be obtained when the
stimulating electrodes are placed at appro- Points to Ponder
priate spots on the skin surface. A few thumb • Low frequency stimulation is given on the
rules must be remembered, in the following surface of the skin.
order of preferences, to obtain best result. The • Excitable tissues underneath the skin are
passive or + electrode is used to complete the stimulated through the transcutaneous
patient circuit and it should be placed pre- route.
36 Handbook of Practical Electrotherapy

• Stimulating current is delivered to the • Test the equipment on yourself before the
excitable tissues through a pair of electro- patient. This helps in building confidence.
des. • Select and prepare appropriate electrodes,
• The electrode connected to the positive check the connecting leads and jacks of any
terminal of the stimulator is commonly damage.
known as the passive/dispersive/collect- • The passive electrode is secured to appro-
ing electrode. priate spot on the body with an elastic
• The electrode connected to the negative strap or Velcro fastener.
terminal of the stimulator is commonly • The active electrode is placed on the
known as the active/stimulating/direct- general location of the motor point of a
ing electrode. superficial muscle in case of monopolar
• The passive electrode is either larger than stimulation or junction of the proximal
or of the same size as that of the active 1/3 and distal 2/3 of the muscle group in
electrode. case of bipolar stimulation (Figs 5.5 and
• The passive electrode may be placed on the 5.6, Plate 1).
origin or insertion of a muscle or muscle • In case of deep muscles, the motor point
group, over the motor nerve supplying the may not be at the designated spot. The
muscle—at its most superficial spot, over stimulus will spread to the overlying
the spinal segment of the motor nerve or superficial muscles, with little benefit to
any other location close to the point of the target deep muscle. In such case, the
stimulation. active electrode should be placed at a spot
• The active electrode is placed over the where any portion of the deep muscle
motor point of the muscle, usually located which is at the surface, e.g. the tendon.
over the junction of the proximal 1/3 and • Set appropriate frequency, waveform and
the distal 2/3 of the fleshy belly of the modulation rate of the stimulating current
muscle. depending on the desired effect and the
nature of target tissue.
The Checklist to follow in Application of
• Gradually increase intensity till the desired
Electrical Stimulation
effect is felt, i.e. contraction of muscles for
• Counsel the patient, explaining in details motor stimulation or tingling sensation for
why the stimulation is needed, how it will sensory stimulation. The level of stimu-
be given and what sort of sensation to lation should never be too uncomfortable
expect. or the patient may not comply with the
• Follow the checklist of contraindications treatment. At end of treatment, gradually
and cautions. decrease the intensity to zero before lifting
• Make the patient comfortable on a wooden the active electrode from the skin. Dis-
plinth, in a well-lit room with privacy to connect the electrodes from the patient and
undress or expose the part to be treated. inspect the skin for any adverse reaction.
• Prepare the skin of the target area to Make a record of the treatment. Allow the
minimize skin resistance and therefore the patient go after a few minutes of stabi-
discomfort. lizing time.
 Getting Started with Low Frequency Electrical Stimulation 37

CLINICAL APPLICATIONS OF LOW • This helps in better recruitment of motor

FREQUENCY STIMULATION units of weak muscles, thereby producing
stronger contractions and quicker gain in
Low frequency electrical stimulation is the
power.
modality of choice in any paralytic conditions.
• Further, since faradic stimulation produces
The visual impact of a flail part, that was so
titanic contraction similar to voluntary
far useless and lifeless, suddenly being
contraction, it is very useful in re-edu-
rejuvenated at the touch of the electrode, is
cation of movements, in lesion of upper
tremendous. The electrical stimulation can do
to the morale of the patient, what words of motor neuron.
counselling from the therapist fail to achieve. • Through biofeedback the patient regains
Hence there is always a temptation among the normal function of the muscle.
therapist to use this modality more frequently • Some patients cannot initiate muscle
than warranted clinically. A clear under- contraction voluntarily to produce move-
standing of the principles of clinical applica- ment, due to inhibition or hysterical
tion of electrical stimulation is essential to paralysis, though there is nothing wrong
prevent this modality from becoming a with their muscles.
gimmick. • In such cases faradic stimulation may be
used to facilitate muscle contraction and
Points to Ponder movement of the body part, to break the
inhibition.
• Low frequency stimulation, using IG • This principle is also used in re-education
current can be applied in all major peri- of new muscle action, in cases where a
pheral nerve injuries,
muscle or tendon has been transferred
• The aim of preserving the physiological
from its original location to different spot,
properties of the muscles supplied by the
to perform a different function.
dysfunctional nerve.
• In presence of swelling in the extremities,
• The rationale is to provide exercise to the
application of faradic stimulation assists
muscle through artificially-induced cont-
in drainage of fluids.
ractions, to promote exchange of blood.
• Fresh blood carries nutrient and oxygen to
TECHNIQUES OF LOW FREQUENCY
the paralysed muscle, to keep its proper-
STIMULATION IN SOME COMMON
ties of contractility, excitability and
CLINICAL CONDITIONS
extensibility intact, till the nerve re-grows
to take over the function of muscle contrac- In the following pages I have dealt with some
tion. common clinical conditions that need low
• Once the muscle has started contracting frequency electrical stimulation. The students
actively, stimulating current may be are likely to face such cases during the course
changed to surged faradic, should be of their supervised clinical practice. Details of
applied simultaneously with voluntary the technique of application, as well as,
contraction. outline of the specific pathophysiology of the
38 Handbook of Practical Electrotherapy

disorder, along with tips on suitable adjunc-

tive therapy, have been covered for easy
reference.

1. Techniques of Low Frequency

Stimulation in Bell’s Palsy
Clinical condition: Bell’s palsy.
Nerve involved: Facial nerve or VIIth cranial
nerve.
Muscles involved: Facial muscles—Frontalis,
corrugators, orbicularis oculi and oris, levator
labi superioris and inferioris, nasalis, risorius
Fig. 5.7: Stimulation of facial muscles in Bell’s palsy-
and mentalis. • Note the stainless steel point active electrode
being used, since the muscle involved is small in
Nature of impairment: Flaccid paralysis of
size, to stimulate the motor point of Risorius or
muscles of one side of the face due to the smile muscle.
compression of the facial nerve, trapped the • The positive passive electrode with eight layers
under zygomatic arch, where it emerges from of lint cover placed under the neck.
the bone.
Functional problems: Loss of facial expressions Duration of treatment: Thirty to sixty contrac-
and symmetry, drooling, conjunctivitis. tions to each muscle.
Type of current used: Interrupted galvanic Special precautions: Facial skin is delicate and
current, rectangular pulses at 100 ms duration subject to rashes and itching on prolonged
at1 pulse per second. As the condition imp- stimulation. Use Betamethasone and zinc
roves, the pulse duration can be progressively oxide based cream in case of rashes or itching.
reduced to 30, 10, 3, 1 ms and the rate of repeti- All facial must be shaved. Use a moisturizing
tion can be increased to 3 pulses per second. lotion after treatment.
Type of technique: Monopolar technique, with Contraindications: Do not stimulate in presence
passive electrode of 5 sq cm carbon rubber of severe acne or skin rashes.
plate, active electrode with 1 sq cm disc on
holder. Remarks: Easiest of cases to stimulate, but
counsel the patient before the treatment.
Patient position: Supine on a wooden plinth. Facial massage and exercise to the facial
Placement of electrodes: With the patient in muscles are essential for faster recovery and
supine position positive electrode placed should be demonstrated to the patient to be
under the neck, negative electrode placed on practiced at home.
the motor points of individual muscles Chewing gum or sipping water through
(Figs 5.7; 5.8, Plate 2; 5.9). straw is also effective form of home exercise.
 Getting Started with Low Frequency Electrical Stimulation 39

Patient position: Sitting on a wooden chair

Placement of electrodes: + ve electrode at the
nape of the neck – ve electrode on the muscle
belly on affected side of the neck (Fig. 5.10).
Duration of treatment: 5-10 min.
Special precautions: The skin preparation must,
to minimize skin resistance, since treatment
time is prolonged. Should use adequate water
in the electrode cover.
Contraindications: The blood pressure of the
patient with neck stiffness must be checked
Fig. 5.9: Position of the patient and the therapist during
before treatment. Neck stiffness may be due
facial stimulation
• The stimulator should be within easy reach of the to high blood pressure, where electrical
therapist so that the controls can be operated stimulation should not to be given because it
comfortably. may increase blood pressure.
• The ambient light should be tangential to detect
slightest contraction of the smallest muscle Remarks: Moist hot packs and gentle manual
mobilization of the neck, with mild traction
component in the pain free range of the neck
2. Technique of Low Frequency
may be given as an adjunct to electrical
Stimulation in Wryneck stimulation.
(Paracervical Muscle Spasm) The patient must be asked to avoid
Clinical condition: Wryneck—muscle spasm of exposure to cold for at least one hour after the
neck and upper back muscles. treatment.

Nerve involved: Spinal accessory nerve (root

value—C1-C4)
Muscles involved: Trapezius upper fibres
Nature of impairment: Muscle spasm and pain
inhibition of neck movement due to postural
stress or cervical spondylosis.
No primary nerve involvement.
Functional deficit: Pain and stiffness of neck
and scapular movements.
Type of current used: Surged faradic current,
with surge duration of 10 sec and surge Fig. 5.10: Placement of electrodes for surged faradic
interval of 30 sec. stimulation to relieve spasm of muscle of the neck-
Carbon rubber plate electrodes of equal size are
Type of technique: Bi-polar technique, both placed on either side over the posterior-lateral
electrodes 5-8 sq cm carbon rubber plates. muscles of the cervical column
40 Handbook of Practical Electrotherapy

3. Technique of Low Frequency

Stimulation in Fibromyositis
of Trapezius Muscle
Clinical condition: Fibromyalgia of para-
scapular muscles or T4 syndrome.
Nerve involved: Dorsal scapular, supra-
scapular and thoraco-dorsal nerve (C4-8).
Muscles involved: Rhomboids, supra and
infraspinati, teres major, subscapularis.
Nature of impairment: Muscle spasm resulting
in ischemia producing fibromyalgia.
Functional deficit: Inhibition of scapular and
shoulder movements, often misdiagnosed as
Fig. 5.11: Placement of electrodes for surged faradic
periarthritis of the shoulder joint. stimulation to relieve spasm of suprascapular muscles.
Type of current used: Surged faradic current Carbon rubber plate electrodes of equal size are
placed on the affected side, covering the upper fibres
Type of technique: Bi-polar stimulation. of trapezius muscles at its proximal and distal ends

Patient position: Sitting on a wooden chair, with

head and the upper girdle resting on a plinth. Type of technique: Bi-polar technique, both
Placement of electrodes: Positive electrode at the electrodes 5-8 sq cm carbon rubber plates.
nape of the neck. Negative electrode at the Patient position: Sitting on a wooden chair
medial border of scapula on the affected side
(Fig. 5.11). Placement of electrodes: + ve electrode at the
nape of the neck – ve electrode on the muscle
Duration of treatment: Surged faradic at 10 sec
belly on affected side of the neck.
duration and 50 sec interval for 5 min
Duration of treatment: 5-10 min.
Special precautions: Nothing specific
Special precautions: The skin preparation must,
Contraindications: Nothing specific
to minimize skin resistance, since treatment
Remarks: Manually-guided scapular move- time is prolonged. Should use adequate water
ments must be given after faradic stimulation in the electrode cover.
to obtain quick gain in power. Moist hot packs
and local ultrasound therapy to fibromyalgic Contraindications: The blood pressure of the
nodules are useful as adjunctive modalities for patient with neck stiffness must be checked
relief of pain. Deep friction massage applied before treatment. Neck stiffness may be due
with the tip of the thumb is also very effective to high blood pressure, where electrical stimu-
in reducing fibromyalgic nodules. lation should not to be given because it may
increase blood pressure.
Type of current used: Surged faradic current,
with surge duration of 10 sec and surge Remarks: Moist hot packs and gentle manual
interval of 30 sec. mobilization of the neck, with mild traction
 Getting Started with Low Frequency Electrical Stimulation 41

component in the pain free range of the neck Remarks: As long as the deltoid is devoid of
may be given as an adjunct to electrical nerve supply, shoulder joint needs to be
stimulation. protected from subluxation with a sling or
The patient must be asked to avoid expo- Bobath cuff. Axial suspension can be given
sure to cold for at least one hour after the when the power is between Gr.I – II. Once the
treatment. re-innervation starts, manually-guided exer-
cises or pendular suspension must be given
4. Technique of Low Frequency
simultaneous with faradic stimulation to
Stimulation in Crutch Palsy
obtain quick gain in power.
Nerve involved: Axillary nerve (root value-C5).
Muscles involved: Deltoid muscle (Ant, mid 5. Technique of Low Frequency
and post. fibres) Stimulation in Erb’s/Klumpke’s Palsy

Nature of impairment: Flaccid paralysis of Clinical condition: Brachial plexus injury

deltoid muscle due to compression of axillary 1. Erb’s palsy
nerve. 2. Klumpke’s palsy

Functional deficit: Loss of shoulder abduction, Nerves involved:

flexion and extension. • Erb’s palsy—Lesion of C5 root, sometimes
C6 root, caused due to traction injury
Type of current used: Interrupted galvanic between head and shoulder girdle, mainly
current, rectangular pulses at 100 ms pulse
during forceps delivery.
duration at 1 pulse per second.
• Klumpke’s palsy—Lesion of C8-T1 roots,
After re-innervations, surged faradic
caused due to traction injury between arm
current may be used to build strength.
and trunk, caused by sudden pull of the
Type of technique: Monopolar for IG and body weight on the arm, when a person
bi-polar for surged faradic stimulation. grabs something to prevent falling from a
Patient position: Sitting on a wooden chair, arm height or trying to get up on a moving bus
resting on wooden plinth. or train.

Placement of electrodes: +ve electrode at the Muscles involved

nape of the neck, -ve electrode at the common • In Erb’s palsy—Deltoid, rhomboids,
motor point of deltoid, 2 cm above the deltoid supraspinatus, infraspinatus, teres minor,
tubercle (Fig. 5.12, Plate 2). biceps brachi, brachialis.
• In Klumpke’s palsy—Long flexor muscles
Duration of treatment: 60-90 contractions in one of the wrist and fingers and intrinsic
sitting for IG stimulation. muscles of the hand.
Surged faradic stimulation at 10 sec
Nature of impairment: Flaccid paralysis of the
duration and 50 sec interval for 5 min
muscles with significant sensory loss.
Special precautions: Nothing specific.
Functional deficit:
Contraindications: Presence of superficial metal • In Erb’s palsy, (C5)—Loss of shoulder
implant in case of #. abduction, external rotation, elbow flexion
42 Handbook of Practical Electrotherapy

and forearm supination and with (C6)- essential when the plexus has been repai-
wrist extension; typical deformity- Police- red surgically. Axial suspension is the
man’s tip. method of choice for exercising the affec-
• In Klumpke’s palsy – Loss of grip (C8) and ted limb. Once the re-innervation starts,
fine movements of hand; with (T1) typical manually-guided active exercises must be
deformity—Claw hand or ape hand. given simultaneous with faradic stimula-
Type of current used: Interrupted galvanic tion to obtain quick gain in power.
current, rectangular pulses at 100-300 ms • In Klumpke’s palsy, early splinting of the
pulse duration, or selective trapezoidal pulses affected hand must be done to prevent
for prolonged stimulation, at 1 pulse per second. irreversible clawing of fingers.
After re-innervations, surged faradic • It’s wise to repeat SD curve at the beginn-
current may be used to build strength or re- ing of electrical stimulation and then
educate muscle action following muscle transfer
repeat at weekly intervals. It may create a
surgery.
reference point of prognosis, to decide for
Type of technique: Monopolar for both I.G. and surgical intervention if the progress is not
surged faradic stimulation. as expected and it’s so much cheaper than
Patient position: Sitting on a wooden chair with EMG/NCV tests.
the affected extremity resting on a plinth in
front of the patient.
Placement of electrodes: +ve electrode at the
para-cervical area on the affected side, -ve
electrode at the motor point of each affected
muscle (Figs 5.13, Plate 2, 5.14, Plate 3; Figs
5.15 and 5.16).
Duration of treatment: 60 contractions in one
sitting for each muscle or group with I.G.
Surged faradic—10 sec duration and 50 sec
interval for 5 min.
Special precautions: No traction should be
applied to the affected limb while handling
because it may cause further injury to the Fig. 5.15: Placement of electrodes for interrupted
plexus. galvanic stimulation of forearm flexor muscle group–
• A stainless steel plate covered with eight layers
Contraindications: Presence of superficial metal of lint is used as the passive (positive) electrode.
implant within the field of stimulation, in case • The passive electrode is placed on the affected
of # of the shoulder girdle bones. side over the medial epicondyle of elbow, covering
the common flexor origin and the proximal
Remarks: portions of wrist and finger flexor muscles.
• In Erb’s palsy, as long as the girdle muscles • The active (negative) electrode is a lint padded
are devoid of nerve supply, shoulder girdle metal disc electrode mounted on a penholder. It
is placed on the belly of individual muscles of the
needs to be supported with a sling or
flexor compartment of the forearm, one after the
airplane splint, to protect the plexus from other, to give each muscle the required number
traction. Such support is particularly of contractions.
 Getting Started with Low Frequency Electrical Stimulation 43

fibular neck due to crossed leg sitting,

sleeping on side lying on a hard surface,
tight leg cuff of orthosis or BK plaster cast,
applied with knee in hyperextension or a
ganglionic growth on the proximal tibio-
fibular ligament.
2. Anterior tibial nerve may be damaged
during insertion of tibial pin during appli-
cation of skeletal traction.
Functional problems: Dropped foot compen-
sated with high stepping gait.
Fig. 5.16: Placement of electrodes for interrupted
galvanic stimulation of intrinsic muscles of the hand- Type of current used: Interrupted galvanic
• A stainless steel plate covered with eight layers
current, rectangular pulses at 100 ms pulse
of lint is used as the passive electrode.
• The passive (+) electrode is placed on the affected duration, 1 pulse per second.
side over the lower 1/3rd of the forearm on the Type of technique: Monopolar technique,
flexor aspect, covering the median and ulnar
nerves at its superficial most point.
passive 5 sq cm carbon rubber plate, active
• The active (-) electrode, stainless steel point 1 sq cm disc on pen holder.
electrode mounted on a penholder. It is placed
Patient position: Supine on a wooden plinth, a
on the belly of individual intrinsic muscle of the
hand, one after the other, to give each muscle roll under the knee to keep the knee in 10-15
the required number of contractions. degrees in flexion.
Placement of electrodes: +ve electrode over the
6. Techniques of Low Frequency neck of the fibula.
Stimulation in Foot Drop/Flail Foot • -ve electrode on the motor points of
individual muscles (Figs 5.17, Plate 3; 5.18
Clinical condition: Foot drop. to 5.20).
Nerve involved:
Duration of treatment: Thirty to sixty contrac-
1. Lateral popliteal (common peroneal) nerve,
tions to each muscle.
most commonly involved.
2. Anterior tibial nerve Special precautions: Rashes and etching on
prolonged stimulation are common. Use
Muscles involved:
Betamethasone and zinc oxide based cream
1. Lat popliteal nerve—Muscles of the
in case of rashes or etching. The leg must be
anterior-lateral compartment of the leg
shaved before treatment to minimize skin
(Tib.ant, EHL, EDL, EDB, Peronei).
resistance. Use a moisturizing lotion after
2. Anterior tibial nerve—As above except
treatment.
Peronei.
Contraindications: Do not stimulate in presence
Nature of impairment:
of open wound or skin rashes.
1. Flaccid paralysis of muscles and loss of
sensation over the dorsum of foot, usually Remarks: Easiest of cases to stimulate, but
due to compression of the nerve against counsel the patient before the treatment.
44 Handbook of Practical Electrotherapy

Fig. 5.18: Placement of electrodes for surged faradic

stimulation of dorsiflexor and evertor muscle groups–
• Two stainless steel plate covered with eight layers
of lint of equal sizes are used as the passive Fig. 5.19: Placement of electrodes for interrupted
(positive) and active (negative) electrode galvanic stimulation of planter flexor muscle groups–
electrodes. • A stainless steel plate covered with eight layers of
• The passive electrode is placed on the affected lint is used as the passive (positive) electrode.
side over the neck of the fibula, covering the • The passive electrode is placed on the affected
common peronial nerve at its superficial most side over the popliteal fossa, covering the posterior
point. tibal nerve at its superficial most point.
• The active (negative) electrode is placed on the • The active (negative) electrode is a lint padded
junction of proximal 2/3rd and the distal 1/3rd of metal disc electrode mounted on a penholder. It is
the belly of muscles on the anteriolateral placed on the belly of individual muscles of the
compartment of the leg, to give all the muscle the posterior compartment of the leg, one after the
required number of contractions. other, to give each muscle the required number of
contractions.

SPECIALISED TECHNIQUES USED IN Functional Problem

LOW FREQUENCY STIMULATION
• Pain in the feet and legs on prolonged
1. Faradic Footbath standing and walking.
• Secondary knock-knee may appear as the
Indication: Flat feet or pes planus, due to
child begins to walk for longer durations.
weakness of intrinsic muscles of the feet,
• It may be a cause for disqualification for
resulting in dropped medial longitudinal
defence services.
arches of the feet.
Plan of Management
Points to Ponder
• Primary cause is usually congenital, due to • The primary management in the case of
cramped space for the foetus within the flat feet depends on the age of detection.
pelvis of the mother. Parents usually detect • If the case is detected as early as 12 months
it as the child begins to walk. the defect can be corrected reasonably by
• Secondary causes may be childhood giving the child corrective foot wears with
obesity, paralysis of foot muscles or medial arch support and exercises like sand
derangement of the bones of the foot due walking, tip toeing, to develop the intrinsic
to injury. muscles of the feet, etc.
 Getting Started with Low Frequency Electrical Stimulation 45

particularly when there is correctible bony

derangement of the feet.

Equipment and Type of Current Used

• Standard low frequency stimulator, offering
surged faradic current with separate controls
for surge duration and intervals.

Type of Electrodes
• Bipolar metal or carbon rubber electrodes,
rectangular plates of 3 × 7 cm.
Fig. 5.20: Placement of electrodes for surged • The passive and active electrodes are of the
stimulation of planter flexor muscle groups – same size.
• Two stainless steel plate covered with eight layers • No lint or sponge electrode cover is needed
of lint of equal sizes are used as the passive
since the treatment is done under water,
(positive) and active (negative) electrode
electrodes. which allows free conduction of current
• The passive electrode is placed on the affected while washing off any electrolyte pro-
side over the popliteal area, covering the posterior duced under the electrodes.
tibial nerve at its superficial most point.
• The active (negative) electrode is placed on the Placement of Electrodes
junction of proximal 1/3rd and the distal 2/3rd of
the belly of muscles on the posterior compartment • The electrodes are placed in a shallow bath
of the leg, to give all the muscle the required of water, the positive under the heel and
number of contractions. the negative under the ball of toes.
• The level of water should be up to the
junction of the dorsal and planter skin of
• When the child is little older, say 3-5 years,
the foot. This will ensure that the current
this therapy may be complimented with passes easily through the intrinsic muscles
faradic footbath, with a little coaxing to in the sole of the foot and does not spread
create acceptance of the electrical stimu- to the dorsum.
lation.
• In cases with milder presentation or with late Application of Current
detection, like in the teen age, faradic footbath
• Surged faradic current, with surge dura-
forms the first choice of therapeutic manage-
tion of 10 sec and interval of 30 sec is
ment, along with medial arch support
applied.
shoes and exercise like toe curling. • The intensity should be enough to produce
The Rationale Behind Faradic Footbath visible contraction of intrinsic muscles of the
foot creating clenching of toes. Patient
• The intrinsic muscles of the foot form the should be asked to curl toes simulta-
dynamic support system for the arches of neously along with the current flow and
the feet. Building up the strength of these relax during surge interval.
muscles with surged faradic stimulation • The treatment should be given for 15-30
helps to stabilize the arches of the feet, min.
46 Handbook of Practical Electrotherapy

Precaution: Do not allow the patient to touch • Collection of fluid in tissue interstitial
the equipment or the wall during treatment. space also interferes with supply of
nutrition and oxygen to the tissue through
2. Faradism Under Pressure blood stream. This may lead to further
Indication: Oedema or swelling of extre- complications like skin breakdown and tissue
mities. necroses.

Points to Ponder Plan of Management

• Such oedema develops in the distal end of • The primary goal in the management of
limbs due to collection of fluid in the tissue pathological oedema is to remove the fluid
interstitial space. from the site of oedema as quickly as
• Common pathological causes are soft tissue possible.
injury like sprain and strain, inadequate • This can be achieved by the combination
lymph or blood drainage due damage to of elevation, compression and isometric
the vessels like deep vein thrombosis or muscle contraction.
following radical mastectomy or systemic • Elevation of extremities utilizes the gravity
disorders like congestive heart or kidney to drain the fluid to the systemic circula-
failure etc. Therapy is indicated for such tion, provided the limb is elevated above
pathological oedema the level of the heart.
• Physiological or gravitational oedema may • Compression applied with crepe bandage
develop in the legs if the limbs hang down or pressure stockings and isometric muscle
for long periods without any movement, contraction helps to push the fluid from
e.g. as in long bus or air journey. The the tissue interstitial space in to the blood
gravitational force pulls fluid down in to or lymphatic vessels.
the lower extremities, which is not pum-
ped out due to lack of muscle contraction. Rationale Behind Faradism
Elevation of the limb and frequent move- Under Pressure
ments are enough for physiological • The process of fluid drainage can be made
oedema. more effective by application of surged
faradic current to major muscle groups to
Functional Problem generate stronger contractions that creates
• The girth of the limb increases and it a pumping action on the muscles and the
becomes heavy, creating problems in joint blood vessels.
movements and locomotion. • When the limb is maintained under
• If allowed to remain undisturbed for long, pressure during such induced contraction,
oedema, which is initially soft and pitting the recoil force of the muscle contraction
under finger pressure, may consolidate or acting against the force of compression
harden. If this happens around a joint, the makes the drainage more effective, further
movement of the joint may be perma- assisted by gravity if the limb is kept in
nently lost. elevation.
 Getting Started with Low Frequency Electrical Stimulation 47

Equipment and Type of Current Used Application of Current

• Standard low frequency stimulator, offer- • Surged faradic current, with surge dura-
ing surged faradic current with separate tion of 30 sec and interval of 90 sec is
controls for surge duration and intervals applied.
• The intensity should be enough to produce
Type of Electrodes visible contraction of muscles of the
• Bipolar carbon rubber electrodes, rectangular creating clenching of toes/fingers.
plates of 3 × 5 cm with sponge electrode • Patient should be asked to do active
cover. The passive and active electrodes movement simultaneously with the cu-
are of the same size. rrent flow and relax during surge interval.
The treatment should be given for 30 min.
Placement of Electrodes
Special Precautions
The skin must be cleaned and moistened
adequately before treatment. Placement of • Skin rashes are common on prolonged
electrodes varies from site to site: stimulation.
• For oedema of the leg, ankle and foot, the • Use Betamethasone and zinc oxide based
active electrode is placed on the calf, cream in case of rashes.
approximately at the centre of the fleshy • The body hair must be shaved before
belly of the muscles. The passive electrode treatment to minimize skin resistance.
is placed on the sole of the foot. • Use a moisturizing lotion after treatment.
• For oedema of hands and forearm the Contraindications: Do not stimulate in pre-
active electrode is placed on the flexor sence of open wound or skin rashes.
aspect of the forearm, approximately at the
junction o the proximal 1/3rd and the 3. Faradism Under Tension
distal 2/3rd of the muscle belly. The
Indication: Shortening of Contractile soft tissue
passive electrodes may be placed on the
like muscles and some type of connective
palm or on the cubital fossa.
tissues in and around joints.
• The electrodes are fixed to the skin with
straps or adhesive tapes. Points to Ponder

Application of Pressure Plan of Management

• With the patient in supine position on a • Such contractures develop in major muscle
wooden plinth, the limb is elevated above groups of the extremities, like the quadri-
the level of the heart, using pillows. ceps or elbow flexor group leading to
• The pressure bandage or garment is restriction of knee flexion or elbow exten-
applied over the electrodes, keeping sion, mostly after prolonged immobilisa-
maximum pressure at the distal most end tion following fractures.
of the limb, becoming progressively less • Conventionally, such tightened muscles
proximally. and soft tissue are mobilized by forced
48 Handbook of Practical Electrotherapy

passive movements, which is an extremely and active over distal 1/3rd over front of
painful procedure. the thigh.
• In contracture of the elbow flexors, passive
Rationale Behind Faradism Under Tension electrode is placed over proximal 1/3rd
• Titanic contraction induced by surged and active over distal 1/3rd over front of
faradic stimulation generates intrinsic the arm
tension in the myofibril, which is made to
Application of Tension
contract against external traction force
trying to stretch them apart. • In case restriction of knee flexion due to
• The interplay of opposing forces pulls apart contracture of quadriceps muscle group
the shortened myofibrils, gradually in- the patient is positioned on wooden plinth,
creasing their length, with much less pain with the legs hanging down. A roll of towel
than would be felt with forced passive is placed below the knee to prevent
movement. posterior translation of the tibia over
• The patient is asked to try and contract the femur. The thigh is strapped to the plinth
tightened muscle as hard as possible in
time with the surge of faradic stimulation.
This adds to the intrinsic contractile force
of the myofibrils, leading to quicker
releases of contracture, as well as power
gain.

Equipment and Type of Current Used

• Standard low frequency stimulator, offer-
ing surged faradic current with separate
controls for surge duration and intervals.

Type of Electrodes
Fig. 5.21: Placement of electrodes for surged
• Bipolar carbon rubber electrodes, rec- stimulation under tension to the quadriceps muscle
tangular plates of 5 × 10 cm with sponge groups –
• Two stainless steel plate covered with eight layers
electrode cover. of lint of equal sizes are used as the passive
• The passive and active electrodes are of the (positive) and active (negative) electrode
same size. electrodes.
The skin must be shaved, cleaned and • The passive electrode is placed on the affected
side over the proximal 1/3rd of the quadriceps.
moistened adequately before placement of
• The active (negative) electrode is placed on the
electrodes, which varies from site to site. junction of proximal 2/3rd and the distal 1/3rd of
the belly of the muscle.
Placement of Electrodes (Fig. 5.21) • The limb is kept at its limit of flexion to give the
muscle the required degree of stretch and then
• In contracture of the quadriceps, passive the required number of titanic contractions is given
electrode is placed over proximal 1/3rd to the muscle under tension.
 Getting Started with Low Frequency Electrical Stimulation 49

with a 6”wide canvas strap. Tension to the • The intensity should be enough to produce
affected knee joint is applied with a sand visible contraction of the muscles.
bag or weighted belt (1/2-3kg) attached to • Patient should be asked to do active
the front of the ankle. movement simultaneously with the cu-
• In case restriction of elbow due to contrac- rrent flow and relax during surge interval.
ture of elbow flexor muscle group, the • The treatment should be given for 30 min.
patient is positioned supine on a wooden
plinth. A roll is placed under the elbow, just Special Precautions
proximal to the joint. The arm is stabilized
with a sand bag placed on the lower end • Skin rashes are common on prolonged
of the arm, keeping the elbow free to move. stimulation.
Tension to the muscle is applied with a • Use Betamethasone and zinc oxide-based
sand bag or weighted belt (1/2-1 kg) cream in case of rashes.
strapped to the anterior aspect of the wrist. • The body hair must be shaved before
treatment to minimize skin resistance.
Application of Current
• Use a moisturizing lotion after treatment.
• Surged faradic current, with surge dura-
tion of 30 sec and interval of 90 sec is Contraindications: Do not stimulate in pre-
applied. sence of open wound or skin rashes.
50 Handbook of Practical Electrotherapy

6
Pain Modulation—
Transcutaneous Electrical
Nerve Stimulation (TENS)
It is a modern, non-invasive, drug-free pain • This pre-synaptic inhibition of the T
management modality, designed to provide cells closes the spinal pain gate to
afferent stimulation, used for relief of acute prevent the painful impulses from
or chronic pain. reaching the sensory cortex, where the
TENS is frequently used to relieve muscle pain is felt.
pain in the neck, back or joint pain of knee, • Pain modulation is thus achieved by
shoulder, etc, arising from work or sport activation of central inhibition of pain
transmission
related injuries, e.g. carpal tunnel syndrome,
B. The Endorphin Release theory states that:
RSI (repetitive strain injuries), as well as,
• Noxious stimulus causes production of
postural musculo-skeletal problems related to
endorphins in the pituitary gland.
faulty working environment.
• Endogenous opiates are also synthe-
PHYSIOLOGICAL EFFECT OF TENS sized in periaquductal grey matter,
midbrain and thalamus.
Two theories are used to justify the relief of • Painful stimulus causes release of these
pain achieved by TENS. opiates in the pain receptor sites in the
brain.
Points to Ponder
• Pain modulation can thus be achieved
A. The Gate Control theory by Malzack and through the descending pathways
Wall in 1972 postulated that: generating body’s own pain killing
• Activation of A-beta fibres simulates chemicals or endogenous opiates.1
the inhibitory interneuron in substantia
gelatinosa located in the dorsal horn of EQUIPMENT AND THE NATURE OF
the spinal cord. TENS CURRENT
• The activated interneuron produces Points to Ponder
inhibition of transmission through pain • Externally applied electrical potential from
carrying A-delta and C fibres. TENS must produce evolved potentials in
 Pain Modulation—Transcutaneous Electrical Nerve Stimulation (TENS) 51

underlying peripheral sensory nerve(s) or is rapid but transient, i.e. no pain is felt as long
receptors on the skin. as the current is on.
• To do this, there must be an adequate
stimulus to cause depolarisation of the Points to Ponder
nerve cell membrane. • Rate: 50-100 Hz
• Relief of pain by selectively stimulating the • Pulse width: 50-100 microseconds
nerve fibres of choice, either large diameter • Pulse shape: Bipolar asymmetric spike
A-Beta fibres or small diameter A-Delta potentials.
fibres by adjusting the parameters of the • Duration of treatment: 20-60 min in one
machine. sitting may be given continuously for 8 hrs
if required.
Characteristics of A-Beta Fibres • Intensity: Between the first threshold of
tingling and less than an intensity at which
• Large diameter, densely myelinated, with
slight discomfort/muscle contraction is
rapid conduction velocity
felt.
• Low capacitance—does not maintain
• Frequency of treatment: Relief only as long
depolarised state for long
as current applied, hence repeated applica-
• Fibres remain excitable to pulse widths as
tion, particularly while working, is recom-
short as two microseconds
mended.
• To excite A-beta fibres, high-frequency
• Uses: Relief of acute and postoperative
impulses with short pulse widths is used.
pain, and in areas of hypersensitivity or
Characteristics of A-Delta Fibres increased muscle tone.

• Light myelination, slower conduction 2. Low Rate TENS

velocity This is acupuncture like strong low-frequency
• High capacitance—longer latency stimulus, useful in relief of chronic pain.
• Fibres are unexcitable with pulse widths Modulation of pain takes place through
below 10 microseconds release of endogenous opiates, which sup-
• To excite A-delta fibres, low-frequency press the pain receptors in the cerebral cortex.
stimulation, with longer pulse width is Effect is relatively slow but lasts longer, i.e.
used. more than hours after treatment.2

DIFFERENT TYPES OF TENS USED IN Points to Ponder

CLINICAL APPLICATION • Rate: 1-5 Hz
• Pulse width: 150-300 microseconds
1. High Rate TENS
• Pulse shape: Monophasic pulses
Most common mode of TENS, used in acute • Intensity: Sufficient to cause visible muscle
or chronic stage of pain syndrome. Modula- twitches within comfortable tolerance
tion of pain takes place by activation of the level of the patient.
gate control mechanism by inhibition of pain • Duration of treatment: 20-30 minutes per
carrying fibres by large diameter fibres. Effect sitting.
52 Handbook of Practical Electrotherapy

• Frequency of treatment: Once or twice a • Pulse width: 50-200 microseconds

day, depending on duration of pain relief • Pulse shape: Asymmetrical biphasic
• Uses: Relief of chronic pain, effective over • Intensity: Comfortable with intermittent
area of tissue or skin disturbance where tingling sensation
destruction of large fibres means that a • Duration of treatment: 20-30 minutes
long pulse width is needed to achieve the • Uses : Suitable for relief of chronic muscle
effect, e.g. diabetic Neuropathy, neuralgia. spasm or a combination of musculoskele-
tal and neurogenic pain of chronic nature,
3. Brief Intense TENS e.g. sciatic syndrome.
Potentially painful, intense stimulation used
to provide rapid short-term pain relief during WAVEFORMS OF TENS
painful procedures like tooth extraction,
Points to Ponder
wound debridement and dressing of wounds,
deep friction massage, forced passive move- • There is no definitive work or publication
ments of joints or passive stretching of soft to support the claim that one waveform is
tissue contractures. Relief of pain is tempo- better than the others.
rary. • Both basic waveforms, asymmetrical
biphasic or monophasic pulses, are used
Points to Ponder in TENS stimulation.
• Rate: 80-150 Hz • The spike and the square waveforms are
• Pulse width: 50-250 microseconds most effective, having a sharp rate of rise,
• Pulse shape: Monophasic pulses which sufficiently depolarizes the target
• Intensity: Strong to the level of pain sensory nerve.
threshold • Most popular waveforms used are bi-
• Duration of treatment: 15 minutes phasic and are balanced so that there is a
• Frequency of treatment: S.O.S. net zero DC component, to prevent build-
• Uses: To suppress pain during potentially up of ion concentrations beneath the
painful procedures. electrodes.

4. Burst Mode TENS MODULATION OF TENS

This form combines the characteristics of high Points to Ponder
and low TENS, leading to release of endo-
genous opiates. The stimulation is well- • Modulation of electrical parameters (pulse
tolerated by patients, even on prolonged rate, pulse width) is offered on some TENS
application, with slower onset of pain relief machines in order to prevent accommoda-
as compared to low TENS. tion of the nerve and receptors to the
stimulus.
Points to Ponder • Its clinical value remains to be assessed,
• Rate: 50-100 Hz, delivered in bursts, of apart from a pulsation, which some
1–4 pulses per second. patients find more comfortable.
 Pain Modulation—Transcutaneous Electrical Nerve Stimulation (TENS) 53

PARAMETERS FOR OPTIMAL CONTRAINDICATIONS FOR TENS

STIMULATION TENS is an inexpensive patient friendly
An optimal stimulation/site should be: modality having a wide range of application
• Strong enough to stimulate the CNS. with superb safety record. However in some
• Suitable for proper placement of electro- types of cases the application of the modality
should be withheld.
des, free of bony or hairy area.
• Patients with demand type pace makers
• Segmentally-related to the source, as well
• Over the chest wall of cardiac patients
as, the site of pain. • Over the eyes, larynx, pharynx over
• Anatomically-distinct, like specific spinal mucosal membrane
segment or the nerves. • Over the head or neck of a patient with
recent history of stroke or epilepsy.
ELECTRODE PLACEMENT
PRECAUTIONS FOR HOME
Since the modality of TENS is still under PRESCRIPTION
exploration, placement of electrodes in TENS
Being a patient friendly device, due to its easy
is controversial. A basic thumb rule is that the
battery operation, compact size and negligible
negative electrodes should be placed distal to weight, TENS units may be used by patient
the positive electrodes. The positive electrodes constantly, like a hearing aid, to have effective
may be located as close to the representative pain control while working or at home. High
spinal segment as possible (Fig. 6.1). TENS is the current of choice in such situa-
The negative electrodes may be located at: tions. Before prescribing the therapist should
• Acupuncture sites ensure the following:
• Dermatome of the involved nerves • Patient can understand and follow ope-
• Over the painful spot rating instructions perfectly. Do not pres-
• Proximal and distal to the pain site cribe it for very old or young.
• The desired pulse width and rate must be
• Segmentally-related myotomes
set by the therapist and then locked in, so
• Trigger points
that these parameters cannot be changed
The exception to the rule is pain due to by accident. The patient should only have
surgical incisions, where the electrodes must access to the intensity control and be able
be placed parallel to each other on either sides to adjust the strength of the stimulation to
of the suture line. Placements rules have to his level of tolerance.
be adapted with multiple channel application • The therapist must coach the patient on
to ensure maximum coverage of large affected basic maintenance of the equipment,
area (Figs 6.2 and 6.3).3 which is similar to a mobile phones.4
54 Handbook of Practical Electrotherapy

Fig. 6.1: General rules for placements of electrodes for application of TENS:
• Carbon rubber plate electrodes of equal sizes (2 cm × 3 cm) are commonly used.
• The electrodes may have two or four pole arrangement, depending upon the extent of area to be covered
and the type of equipment available.
• As a thumb rule, the positive electrode is placed proximally over the spinal segment representing the
neural supply of the target area.
• The active electrodes may be placed over the distal most point of the target nerve or over the dermatome
of the target segment.
 Pain Modulation—Transcutaneous Electrical Nerve Stimulation (TENS) 55

Fig. 6.2: Specific placement of electrodes for application of TENS for various
painful conditions on the posterior surface of the body

Fig. 6.3: Specific placement of electrodes for application of TENS for various
painful conditions on the anterior surface of the body
56 Handbook of Practical Electrotherapy

APPLICATIONS OF TENS IN COMMON DISORDERS

Disease conditions Type of current Current parameters Electrode placement

Tension Headache Burst Pulse duration—50 microsecond Crossed 4 pole, 2 each over the
Pulse frequency—100 Hz origin and insertion of bilateral
Burst frequency—10 Hz Trapezius muscle upper fibres,
Dose—15 Minutes strong tingling felt.
Frozen Shoulder Burst Pulse duration—40 microsecond Cross 4 pole around the
(chronic Stage) Pulse frequency—100 Hz shoulder joint
Burst frequency—2 Hz
Dose—15 Minutes
Postherpetic Burst Pulse duration—50 microsecond 4 Pole method: 2 over the
Neuralgia Pulse frequency—100 Hz affected area and 2 above
Burst frequency—10 Hz and below the exit nerve
Dose—15 Minutes root.
Neuralgia Continuous Pulse duration—42 microsecond 2 or 4 Pole method over the
Pulse frequency—100 Hz affected area.
Dose—10-15 Minutes

Reflex Sympathetic Continuous Pulse duration—42 microsecond 4 Pole method: a) U/L: 2

Dystrophy Pulse frequency—160 Hz Electrodes at paravertebral
Dose—10-15 Minutes region of C-8 to T-9 and 2
electrodes over levator
scapulae and lateral part of
spine of scapula.
b) L/L: 2 Electrodes over para-
vertebral region of T-10 to L-2
and 2 electrodes over the iliac
crest and lateral part of buttock.
Postoperative Pain Continuous Pulse duration—40 microsecond 4 Pole method: 2 proximal
Pulse frequency—100 Hz and 2 distal to operated area.
Dose—10-15 Minutes
Menstruation Pain Continuous Pulse duration—100 microsecond 2 Pole method: over the
Pulse frequency—80 Hz sacrum bilaterally.
Dose—15 Minutes

Stress Incontinence Surge Pulse duration—100 microsecond 2 Pole method

Pulse frequency—60 Hz
Dose—15 Minutes

REFERENCES 3. Walsh D, Baxter D. Transcutaneous electrical

nerve stimulation—A review of experimental
1. Walsh D. TENS: Clinical Applications and studies. European Journal of Medical Rehab
Related Theory. Churchill Livingstone, 1997. 1996;6(2):42-50.
2. Ellis B. A retrospective study of long-term users 4. Roche P, Wright A. An investigation into the
of TNS. British Journal of Therapy and Rehabi- value of TENS for arthritic pain. Physiotherapy.
litation 1996;3(2):88-93. Theory and Practice 1990;6:25-33.
 Advanced Applications of Low Frequency Electrical Stimulation 57

7
Advanced Applications
of Low Frequency
Electrical Stimulation
Ongoing research and the constant quest HIGH VOLTAGE PULSED GALVANIC
among professional working in the field, for STIMULATION (HVPGS)
effective modalities to achieve quick results
HVPGS is relatively uncommon form of
have yielded different applications of low
stimulating current modulation, used pri-
frequency currents. Some of theses applica-
marily to achieve stimulation of deeper
tions like the high voltage pulsed galvanic
tissues, useful for sensory stimulation for pain
stimulation and functional electrical stimu-
relief and to assist in wound healing.
lation are results of such quests. Advent of
microprocessor technology has been at the
Parameters of HVPGS Current
root of designing sate of the art stimulators
at affordable prices that has helped to • HVPGS current consists of monophasic,
popularise these applications. twin peak pulses of 7 to 200 microseconds
Few applications, like the iontophoresis duration, delivered at 300 to 500 volts.
had been in use in the past decades but had • The twin peak pulse are spike-shaped,
fallen out of favour due to lack of suitable rising and falling rapidly
water soluble ionic mediums in those times. • As pulses rise and fall rapidly, the second
Nowadays, due to the progress made in spike cancels out the irritation produced
pharmacy sciences many therapeutically by the first spike.
useful active ions are available in water- • The modulation may be continuous,
soluble gel form, which are easily absorbed pulsed at 80 to 100 pulses per second or
by the body through the skin and are suitable surged.
for use in iontophoresis. Due to this there is • The passage of HVGS is relatively easy
resurgence in interest among therapists because it is offered little resistance by the
towards this time-tested modality. skin due to higher frequency.
58 Handbook of Practical Electrotherapy

• The specific duration and voltage require- • Cover the clean wound with several layers
ments vary depending upon the condition of sterile gauze soaked in saline.
being treated. • Place the active electrode over the gauze.
• If the wound has chronic infection, to get
Effects and Uses of HVPGS antibiotic effect, the active electrode
should have negative polarity.
• Application of HVPGS tends to produce
• If the wound is free of infection, to promote
comfortable tingling sensation and paras-
healing, the active electrode should have
thesia that closely resembles high fre-
positive polarity.
quency TENS.
• The passive electrode must be three times
• It is used for relief of neurogenic pain
the size of active electrode and placed
through stimulation of trigger points,
proximal to the active electrode.
relaxation of deep muscle spasm and
• The intensity must be gradually increased
wound healing.
to a comfortable level.
• The duration of treatment should be 30 to
Instrumentation of HVPGS
60 minutes, for one sitting, on alternate
• HVPGS therapy is applied through high days.
voltage direct current generators, capable
of producing extremely short duration FUNCTIONAL ELECTRICAL
pulses (microseconds), generally in the STIMULATION (FES)
range of 300 to 500 volts. Functional electrical stimulation, also known
• Standard electrodes used for low voltage as functional neuromuscular stimulation, is an
low frequency stimulation, is used for adapted version of motor stimulating current
HVGPS. modulation, similar in physiological charac-
• The protocol for electrode placement and teristics to the surged faradic stimulation,
treatment is similar to low frequency or used for activation of innervated muscles.
TENS for relief of muscle spasm and
trigger point pain. Parameters of FES Current
• It is more specifically used for wound
The current used is asymmetrical bi-phasic with
healing.
high amplitude negative phase followed by low
amplitude positive phase.
Application of HVPGS in Wound Healing
• The pulse frequency is in the range of
• The patient is positioned comfortably on 12 to 100 Hz, with continuous modulation.
a plinth. The wound is exposed with the • Intensity of current: 90 to 200 milli ampere.
rest of the body covered. • Pulse duration: 20 to 300 microsecond.
• Inspect the wound closely for any slough. • Voltage: 50 to 120 volts.
• The wound must be cleaned and debrided
Effects and Uses of FES
before application of HVPGS, since infec-
tion may interfere with the beneficial effect • This type of current is suitable for produc-
of HVPGS. ing controlled titanic contraction of muscles,
 Advanced Applications of Low Frequency Electrical Stimulation 59

which generates adequate torque to produce pain and inhibition of movement in the
functional movements, in the absence of upper extremity.
adequate voluntary contraction. • Conservative management of such painful
• It is widely used to: shoulder involves a supportive cuff
1. Prevent or correct disuse atrophy, (Bobath cuff) to relive the stretch on the
2. Improve ROM in stiff joints, reduce rotator cuff tendons and ligaments.
muscle spasm or spasticity, • FES is used as supplement to the Bobath
3. Re-education of new muscle action in cuff, in such subluxated shoulder to
case of muscle or tendon transfers increase the supportive action of the key
4. Most commonly used for trial, supple- muscles of the rotator cuff and relieve the
mentation or substitution of orthosis. painful structures of constant painful
stretch.
Instrumentation of FES • Current parameters—Asymmetrical, bi-
1. Stimulator: Specialized FES stimulators are phasic, square wave pulses with conti-
rechargeable battery operated compact nuous modulation may be used, applied
devices, providing option for continuous from a standard faradic stimulator or
modulation of pulse amplitude, duration rechargeable battery operated portable
stimulator.
and frequency, which can be carried by the
• Electrode placement—Bipolar surface
patient like a hearing aid. The slandered
electrodes, carbon rubber type may be
surged faradic stimulator may be used for
used. One electrode is placed on the
treating of localized complaints that
supraspinatus muscle belly just above the
involve no mobility.
spine the scapula and the other should be
2. Leads: Flexible and thin, such leads are
placed on the posterior fibres of deltoid
0.5 to 1.5 meters in length and have a high
muscle.
degree of resistance to torsion and strain.
• Treatment procedure
3. Electrodes:
1. The patient is placed in high sitting on
a. Self-adhesive pre-gelled electrodes.
a wooden chair, with the arm sup-
b. Carbon rubber electrodes.
ported in front, on a wooden plinth.
2. The arm and the shoulder girdle are
Application of FES in
exposed. The procedure and its poten–
Hemiplegic’s Shoulder
tial benefits are explained to remove
• Hemiplegic patients with one-sided any anxiety felt by the patient.
paralysis of the body may have flaccid 3. The skin is prepared, the equipment is
paralysis of deltoid and supraspinatus tested and the electrodes are fixed to
muscle, resulting in subluxation of the the skin with straps or adhesive tapes.
glenohumeral joint. 4. The intensity should be adequate to
• The force of gravity tends to pull the produce tetanic contraction of target
unsupported upper extremity downwards muscle, within the limit of patient’s
causing stretching of the rotator cuff, tolerance. Patients with CVA may be
resulting in ischemia, that produces severe hypertensive. Therefore special care
60 Handbook of Practical Electrotherapy

should be taken not to cause any duration of 225 microseconds are used,
distress to patient. applied from a rechargeable battery
5. The pulse rate is adjusted to 12 to 25 operated portable stimulator.
pulses per second. • Electrode placement—Bipolar surface
6. The on-off ratio between surge dura- electrodes, carbon rubber type may be
tion and surge interval should start used.
with 1:3, i.e. 2 seconds on and 6 seconds 1. In case of single curve—Place two
off. The patient must be encouraged to electrodes from a single channel machine
contract the muscle voluntarily with 2” lateral to the spine, on the convex side
the current surge. The ratio is gradually of the curve, placed above and below the
progressed to 12:1, i.e. 24 seconds on ribs attached to the vertebra at the apex of
and 2 seconds off as the muscles gain the curvature.
power. 2. In case of a ‘S’ curve—Place four
7. The duration of treatment should be for electrodes from a two channel machine,
15 to 30 minutes in one sitting and placed convexity, on either side, placed
should be repeated twice initially. Later above and below the ribs attached to the
the treatment may be given daily for vertebra at the apex of the curvature.
up to 6 to 8 hours.
Treatment Procedure
Application of FES in Idiopathic Scoliosis
• Idiopathic scoliosis is the gradual side- 1. FES in scoliosis should be applied, with the
ways curving (Lateral curve) of the brace on, with a portable stimulator, which
vertebral column, commonly seen in the patient can continue to use while
growing children. performing normal activities.
• Teenage girls are the commonest victims 2. The electrodes are positioned as detailed
of this disorder, which can result in severe above under the straps of the brace and
spinal deformity. then the straps are tightened to give opti-
• Before the bony maturity has taken place, mum tension on the curvature and maxi-
such disorder can be rectified with CTLSO mum contact to skin.
spinal brace. 3. The intensity is increased within the limit
• CTLSO spinal brace or Milwaukee brace of tolerance, to produce titanic contraction
works on the principal of a static brace of paravertebral muscles.
with dynamic correction. 4. The pulse rate is adjusted to 25 pulses per
• FES can be used in cooperative candidates, second.
to supplement the corrective function of 5. The surge duration/interval ratio should
the brace, by encouraging the contraction be 1:1, i.e. 6 seconds on and 6 seconds off.
of posterior spinal muscles, in a prog- 6. The duration of the treatment may be up
ressive deformity, when the spinal curva- to 8 hours. The patient must be encoura-
ture (Cobb’s angle) is between 20 and 45°. ged to perform the self-stretch exercise
• Current parameters—Interrupted mono- with braces on, while undergoing FES, to
phasic rectangular pulses with pulse get best results.
 Advanced Applications of Low Frequency Electrical Stimulation 61

Application of FES in Foot Drop xion of the ankle as preparation to heel

strike.
• Inability to dorsiflex the ankle voluntarily
6. As soon as the heel comes in contact
results in foot drop.
with the ground, pressure sensitive feet
• During the heel strike of the gait cycle, foot
switch cuts off the flow of the current,
drop is the most important cause of gait
allowing the foot-flat to take place
deviation i.e. circumduction gait, in hemi-
during the stance phase.
plegic patients.
7. The duration of the treatment may be
• FES, if applied to the affected leg during
up to 8 hours, during walking. The
walking, can be used to control foot drop
patient must be encouraged to perform
by stimulating the action of dorsiflexors of
the exercises for dorsiflexon with
the ankle and evertors of the foot, at the
braces on, while undergoing FES, to get
swing phase of gait.
best results.
• Current parameters—Asymmetrical bi-
phasic or square wave pulses with pulse IONTOPHORESIS: ION TRANSFER
duration of 20 to 250 microseconds, app- WITH DIRECT CURRENT
lied from a rechargeable battery operated It a specialized technique of electrical stimu-
portable stimulator. lation that uses electrical polarity of continuous
• Electrode placement—Bipolar surface direct current to ionize medicinal agents placed
electrodes, self-adhesive pre-gelled type beneath surface electrodes and transfers them
may be used. One electrode placed on the into the body through the skin or mucous
peroneal nerve at the neck of fibula and membrane.
the other should be placed on the muscles
of anterior-lateral compartment of the leg. How does Iontophoresis Work?
• Treatment procedure: • With iontophoresis, weak electric current
1. FES in foot drop can be applied, with a is used to introduce medication through
portable stimulator, with the brace/ the intact skin to the underlying tissue.
AFO on, which the patient can continue • The medication is supplied directly in to
to use while performing normal acti- the area that will be treated—a form of
vities. pharmacological sharp-shooting.
2. The electrodes are positioned as de- • Systematic affect is reduced to a minimum
tailed above under the straps of the and no adverse effects have been reported.
brace and then the straps are tightened Iontophoresis is an effective and pain-free
to give maximum contact to skin. treatment method.
3. The intensity is increased within the • It is based on the principle that, electrical
limit of tolerance, to produce titanic stimulation affects the ions in a solution
contraction of target muscles. so they may move, depending on their
4. The pulse rate is adjusted to 30 to 300 charge.
pulses per second. • With iontophoresis the polarity that
5. The flow of current is turned on during corresponds with the charge of the medica-
the swing phase to produce dorsifle- tion’s ion is connected to electrode.
62 Handbook of Practical Electrotherapy

• This entails the repelling of the active Dosimetry of Iontophoresis

pharmaceutical ion, which results in the The number of ions transferred through the
medication being introduced down skin depends on:
through the skin. 1. Duration of treatment
2. Current density or current intensity per
Biophysics of Iontophoresis square cms area of the electrodes.
3. Concentration of ions in the medium used
• Transfer of ions depends on the principle in iontophoresis.
of “Like poles repel and opposite poles Based on the above the formula to cal-
attract each other”. culate quantity of substances introduced
• Dissolved acids, bases, salts or alkaloids through iontophoresis is:
in a watery solution break down into I × T × ECE = grams of substances intro-
charged particle or ions. duced through skin, where,
• Ions are charged particles, with positive or • I—stands for intensity of direct current in
negative charge, that can be pushed amperes
through the skin by a similar charge • T—stands for duration of application in
hours
applied to the electrode placed over it or
• ECE—stands for standardized ionic trans-
pulled through the skin by a oppositely-
fer coefficient with fixed current and time
charged electrode placed away from it
factors.
• These ions, on entering through the skin, • The dosimetry of iontophoresis is fairly
combines with other ions and radicals present controversial, due to conflicting reports.
in the blood stream to form new compounds • It has been reported that low ampere
that are therapeutically valuable in specific current has a better effect in ion transfer
disease conditions. because of less resistance offered by the
• Selection of suitable ionic compounds and than high intensity current.
placing them under appropriately charged • It has also been suggested that lower
electrode is the key to the success of concentration of active-charged ions in the
iontophoresis. iontophoresis medium is far more effective
• Low voltage (<100V) monophasic conti- because of less repelling going on between
the like-charged ions themselves, which
nuous direct current, applied at low
allows better penetration.
intensity (<5 mA), applied over low ionic
• By and large, for effective ion transfer it is
concentration (1-5%) in the iontophoresis
recommended to use maximum 5 m. amp
medium is most effective in producing current applied over a medium with active
desired result. ion concentration of 1-5%.
• Direct current applied is not the treatment,
but only the means of ion transfer. Indications for Iontophoresis
• Efficacy of the treatment will depend on There are three main areas of treatment for
selection of specific ionic medium, aimed at iontophoresis:
producing a specific reaction, to treat a • Cortisone treatment of superficial local
specific disorder. inflammations.
 Advanced Applications of Low Frequency Electrical Stimulation 63

• Quick and effective surface anaesthesia with • The skin is as anaesthetized within 10
a local aesthetic. minutes of iontophoresis, as compared to
• To treat hyperhydrosis or excessive sweat- 60 minutes with local anaesthetic cream.
ing in the palm of the hands, soles of the
feet or axilla. Application of Iontophoresis in
Hyperhydrosis
Application of Iontophoresis in
• Tap water iontophoresis is considered by
Local Inflammation
many dermatologists to be the first line of
• Iontophoresis has shown good results in treatment for hyperhidrosis of the palms and
treatment of acute and sub-acute super- soles.
ficial local inflammations, such as ten- • Although more cumbersome, iontopho-
donitis, bursitis, and fasciitis. resis can be used to treat axillary hyper-
• Administration of cortisone using ionto- hidrosis as well.
phoresis is a pleasant alternative to • In addition to simple tap water, anticholi-
cortisone injections. nergics and other drugs can be introduced
• The anti-inflammatory effect is achieved to areas affected by hyperhidrosis.
while avoiding the adverse effects for
systemic or injected cortisone. Which Medications may be
• Effective alternative to treatment with anti- Used as Ionising Agents?
inflammatory tablets or NSAIDs. Medications or mediums that are used with
• With iontophoresis a higher concentration of iontophoretic treatment must be water-
the medication is obtained locally in the tissue soluble and ionisable.
while systemic effect is avoided.
• Commonest sites of application are medial Local Inflammation
and lateral epicondylitis, Achilles tendo- Hydrocortisone in a water-soluble base or gel
nitis, inflamed ligaments of knee, bicepital at 1-10% concentration by volume may be
tendonitis, shoulder rotator cuff tendo- used. This medium has a negative charge, so
nitis/tenosynovitis, carpal tunnel syn- the negative pole (black) must be connected
drome etc. to the medication electrode.

Application of Iontophoresis in Local Anaesthesia

Local Anaesthesia Xylocaine hydrochloride solution or gel used
• With iontophoresis, superficial local for local anaesthesia, at 1% concentration is
anaesthesia can be achieved quickly and recommended medium. Xylocaine has a
effectively by supplying the drug, without positive charge, so the positive pole (red) must
needles and without pain. be connected to the medication electrode.
• The method is faster and penetrates deeper
than local anaesthesia and is excellent Electrodes for Iontophoresis
alternative for anaesthetizing before injec- The electrodes used in iotophoresis have to
tions, wound dressing or taking blood/ be specifically tailor made for a specific site
tissue samples. and patient.
64 Handbook of Practical Electrotherapy

• Use aluminium foil, cut in square or round though these are much more expensive
shape, large enough to cover the entire than aluminium foil electrodes.
skin surface of the target area. • The passive electrode is placed at a site
• The active electrode should be bigger than away from the site of stimulation.
the passive, to provide for low current • Electrodes are secured with straps or
density, which helps in better penetration adhesive tapes (Figs 7.1A and B, Plate 4)
of ions. • Calculate the dosage as per the guidelines
• The aluminium foil electrodes are covered given above. Remember that the safe limit
with 8 to 10 layer of tissue paper, which for positive active electrode is 1.0 mA/sq
can be discarded after single use. cm and negative active electrode is 0.5
• The active electrode is soaked in the active mA/sq cm.
ingredient solution made of distilled • Turn the intensity gradually to the safe
water. limit.
• The passive electrode is soaked in tap • Keep close watch over the treatment area.
water. In case of hyperhydrosis both Inspect the site after every 5 mins. If there
electrodes are soaked in tap water. is itching or burning stop treatment
immediately.
Technique of Application Iontophoresis • After 20 to 30 min of treatment slowly turn
the intensity to zero.
• Clean and soak the skin to reduce the skin
• Remove the electrodes; inspect the area for
resistance. If there are cuts or break in the
rash or reddening. Slight reddening is
skin, apply a thin layer of sterile petroleum
expected.
jelly on the spot.
• Wash the area thoroughly with water and
• Position the patient on a wooden plinth.
allow the patient to leave.
Support the area to be treated with pillows.
• Rub the medium containing the active
Contraindications of Iontophoresis
ingredient on the skin over the spot to be
treated. • Impaired skin sensation
• Active electrode having the same polarity • Allergy or rashes
as the active ion is placed on the area to be • Recent scar
treated. Special medicated active electro- • Broken skin
des are available readymade in the market, • Metal in the treatment area.

Ions commonly Used in Iontophoresis and Their Clinical Indications

Ions Polarity Source Indications

Lidocaine/Xylocaine + Lidocaine/Xylocaine gel Local anaesthesia

Salicylate – Sodium salicylate gel Relief of pain and inflammation
Acetate – Acetic acid Dissolve calcification of soft tissue
Zinc + Zinc oxide solution Skin ulcers
Copper + Copper sulphate solution Fungal infection
Calcium + Calcium chloride Muscle spasm
Magnesium + Magnesium sulphate do
Dexamethasone + Dexamethasone 1% gel Soft tissue inflammation
 Medium Frequency Currents 65

8
Medium Frequency
Currents
• Sine wave current, in the frequency range • The result of applying such medium
of 2000 to 5000 Hz, modulated to produce frequency current is that it will pass more
physiological response in nerves are called easily through the skin, requiring less
the medium frequency currents. electrical energy to reach the deeper
• The basic advantage of medium frequency tissues, therefore producing less discom-
stimulation over conventional surged fort.
faradic current, is its ability to produce the
strong physiological effects of low fre- TYPES OF MEDIUM FREQUENCY
quency electrical stimulation, in much CURRENT
deeper muscle and nerve tissues, without
Medium frequency current can be broadly
the associated painful and unpleasant
categorized in to two forms:
sensation of low frequency stimulation.
1. Medium frequency surge current
• To produce low frequency effects at
2. Interferential current
sufficient intensity at depth, most patients
experience considerable discomfort in the Medium frequency surge current is a two-
superficial tissues (i.e. the skin). pole interference current, which increases and
• This is due to the resistance (impedance) decreases in intensity over a set duration and
of the skin being inversely proportional to interval, like the surged faradic current.
the frequency of the stimulation. In other It is far well-tolerated by the patient than
words, the lower the stimulation fre- faradic stimulation and the etching effect of
quency, the greater the resistance to the IG stimulation are not seen
passage of the current and so, more It is available in two formats;
discomfort is experienced. 1. Russian current with carrier frequency
• The skin impedance at 50 Hz is approxi- of 2500 Hz
mately 3200 ohms whilst at 4000 Hz it is 2. MF surge current with carrier fre-
reduced to approximately 40 ohms. quency of 4000 Hz.
66 Handbook of Practical Electrotherapy

Russian Current • It is more useful for relief of pain and

improving circulation in muscles.
• It is a polyphasic sine wave continuous
current having a basic or carrier frequency • Though it causes significant muscle con-
of 2500 Hz. traction, it is less powerful than produced
• The current is frequency modulated to with Russian current.
produce a train of pulses with a pulse
duration of 10 ms and a pulse interval of INTERFERENTIAL CURRENT
10 to 50 ms.
Interferential current utilizes two amplitude
• Such frequency modulation produces 50
modulated medium frequency sinusoidal
to 10 pulses in one second, each pulse
currents; in the frequency range of 4000 to
lasting for 10 ms.
• It is applied in bi-polar mode, usually with 5000 Hz. These are called the carrier cur-
carbon rubber or vacuum electrodes. rents.The carrier current in both channels has
• It is effective in muscle strengthening and the same amplitude but the frequencies of are
for relief of muscle spasm. kept slightly out of synchronization.The
carrier currents are passed through the tissues
Method of Application simultaneously, so that their paths cross and
For muscles strengthening, the intensity is interfere with each other’s field deep within
adjusted to produce strong titanic muscle the tissues.This interference gives rise to
contraction, using a pulse rate of 50 to 70 amplitude modulated frequency, like the
pulses per second with pulse duration of 150 strings of a sitar, to produce a pulsing effect
to 200 microseconds. The current is applied or beat; wherever they cross each other. When
during volitional activities like isometric the two carrier waves are in phase, construc-
contractions in different ROM, slow speed tive interference takes place. The resultant
isokinetic and short arc isotonic movements.
beat frequency has an amplitude (intensity)
Primary effects are to build up muscle power
that is the sum total of the amplitudes of the
delivery in different range of motion or
carrier currents when the carrier waves are
mobilize stiff joints. The stimulation is applied
to produce contraction for 15 seconds and 180 degree out of phase, destructive inter-
relaxation for 50 seconds. ference cancels out the carrier amplitudes. The
For relief of muscle spasm, titanic contrac- resultant beat frequency has amplitude
tion is produced to the limit of tolerance a (intensity) of zero. The beat frequency current
pulse rate of 50 to 70 pulses per second, with has the characteristics of low frequency
pulse duration of 50 to 170 microseconds. The stimulation (Fig. 8.1).
stimulation is applied to provide brief • The exact frequency of the beat frequency
isometric contractions for 5 to 12 seconds and can be controlled by the input frequencies
8 to 15 seconds of relaxation. • If one carrier current is at 4000 Hz and its
companion current at 3900 Hz, the resul-
MEDIUM FREQUENCY SURGE CURRENT tant beat frequency would be the diffe-
• It is a polyphasic sine wave continuous rence of the two carrier frequencies i.e. 100
current having a basic or carrier frequency Hz, spreading in a typical clover leaf
of 4000 Hz. pattern (Fig. 8.2B).
 Medium Frequency Currents 67

• Modern machines usually offer frequen-

cies of 1 to 150 Hz, though some offer a
choice of up to 250 Hz or more.
• To a greater extent, the therapist does not
have to concern themselves with the input
frequencies, but simply with the appro-
priate beat frequency, which is selected
directly from the machine.
• In 2 pole interferential stimulation, where
there is clearly no interference within the
body, is made possible by electronic mani-
pulation of the currents, i.e. the inter-
ference occurs within the machine. This is
suitable for small areas like sinus, tem-
poro-mandibular joints etc.

Fig. 8.1: Principle of interference using two Physiological Effects of

channels of medium frequency currents Interferential Current
• Excitable tissues can be stimulated by low
• The amplitude modulated beat frequency
frequency alternating currents.
may be constant or variable. • All tissues in this category will be affected
• Constant beat current is obtained when
by a broad range of stimulations
both the carrier frequencies remain fixed.
• Savage in 1984 postulated that different
• Variable beat current is obtained when one
tissues will have an optimal stimulation
carrier remains fixed and the other keeps
on changing in frequency at regular band, which can be estimated by the
intervals from a lower to a higher level and conduction velocity of the tissue, its
back, known as sweep. latency and refractory period.
• This produces a spectrum of frequencies • These are detailed below:
in the beat current at regular sweep. Sympathetic nerve: 1 to 5 Hz
• Such sweep prevents accommodation of Parasympathetic nerve: 10 to 150 Hz
nerves. Motor nerve: 10 to 50 Hz
• By careful manipulation of the input Sensory nerve: 90 to 100 Hz
currents it is possible to achieve any beat Nociceptive fibres: 90 to 150 Hz
frequency to use clinically. Smooth muscle: 0 to 10 Hz.
• Classical interferential (static) field is
generated when the beat current remains Therapeutic Effects of
constant. Interferential Current
• Vector current (dynamic) field is produced
when the interferential field rotates by 45 • The clinical application of IFT therapy is
in clockwise or anticlockwise direction based on response threshold and the
within the tissue, constantly changing the physiological behaviour of stimulated
stimulation zone. tissues.
68 Handbook of Practical Electrotherapy

• Selection of a wide treatment band can be

considered less efficient than a smaller
selective band because by treating with a
frequency range of say 1 to 100 Hz, the
appropriate treatment frequencies can be
covered, but only for a relatively small
percentage of the total treatment time.
• Additionally, some parts of the range
might be counterproductive for the pri-
mary aims of the treatment.
• Main clinical applications of IFT are:
1. Pain relief
2. Muscle stimulation Fig. 8.2A: Advanaced Interferential equipment: The
3. Increased blood flow Phyaction 787 stimulator with microprocessor
4. Reduction of oedema controlled circuits is a later generation equipment that
5. Tissue healing and repair. offers a wide range of stimulating current selection in
• Since IFT acts primarily on the excitable low and medium frequency range, with ultrasonic
therapy module which can be used for combination
tissues like nerves and muscles, the
therapy or as an independent modality (courtesy M/
strongest effects are likely to be those S Hintek Electronics, New Delhi). Note four channel
produced by such stimulation, i.e. pain conventional carbon rubber plate electrodes
relief and muscle contraction. connected to the machine through colour-coded
• The other effects like drainage of fluid and leads. On the left of the plate electrodes are four
reduction in muscle spasm are secondary sockets for vacuum suction electrodes. Unlike the
consequences of the primary effects. plate electrodes, the vacuum suction electrodes do
not need straps to hold them in place, hence are easy
to apply over irregular surfaces.
Instrumentation of IFT
Most modern IFT units (Figs 8.2A and 8.3)
allow the therapist to get tailor made current,
suitable to treat a specific disorder, which may
be built in to the memory of the software
based equipments or by adjustment of
following machine parameters:
• Amplitude modulation parameter (AMF),
to choose the basic value of the low
frequency modulation that is desired.
• Spectrum parameter, to set the range of Fig. 8.2B: Advanaced interferential equipment: The
LCD display of Phyaction 787 in classical interference
variation in the AMF value that is desired;
current mode, showing amplitude modulated
setting the AMF at 100 Hz and spectrum frequency at 100 Hz, nil spectrum or sweep
at 50 Hz will give an AMF variation from frequency, sweep time of 1sec and a rise or fall rate
100 Hz upto150 Hz and back to 100 Hz.The of surge at 67 per cent. The clover leaf pattern of the
spectrum is useful in preventing accom- classical interference current is also shown along with
modation in nerves (Fig. 8.2B). intensity of each channel and the treatment timer
 Medium Frequency Currents 69

mechanisms and thereby mask the pain

symptoms for the duration of application.
• Alternatively, stimulation with lower
frequencies (1-5 Hz) can be used to activate
the release of indigenous opiates, provid-
ing long-term relief of pain.
• These two different modes of action can
be explained physiologically. Each has
different latent periods and varying
duration of effect.
• Relief of pain may be achieved by stimu-
lation of the reticular formation at fre-
Fig. 8.3: Overall arrangement of the interferential quencies of 10 to 25 Hz or by blocking C
therapy instrumentation (equipment and electrodes) fibre transmission at frequencies greater
in a clinical setting
than 50 Hz.

• Sweep time parameter sets the time period for Treatment Parameters to Achieve Muscle
the AMF to change from base to peak Stimulation with IFT
frequency. Faster the sweep less painful is
• Stimulation of the motor nerves can be
the stimulation. However, if strong muscle
achieved with a wide range of frequencies.
contraction or sensory input is desired,
• Stimulation at low frequency (e.g. 1 Hz)
then the sweep must be slow, to ensure
will result in a series of twitches:
aggressive stimulation.
• Stimulation at 50 Hz will result in a titanic
• Contour parameter sets the rate of change of
the AMF from base to peak frequency. This contraction.
is expressed in percentage of time taken • The choice of treatment parameters will
to reach from base to peak of AMF. Greater depend on the desired effect.
the percentage, the gentler is the sti- • To combine muscle stimulation with an
mulation. increase in blood flow and a possible
• Rotation parameter is applicable in case of reduction in oedema, selecting a frequency
vector currents only and sets the rate of range which does not produce strong
rotation and the direction of change of the sustained titanic muscle contraction.
AMF field within the tissues. • In such cases, a sweep of 10 to 25 Hz is often
used, to produce pumping effect on the
Treatment Parameters to Achieve target muscles, which will help in drainage
Pain Relief with IFT of fluid from the interstitial space.
• Electrical stimulation for pain relief has • There is no primary nervous control of
widespread clinical use. oedema re-absorption and the direct
• Direct research evidence for the use of IFT electrical stimulation of blood flow is
in pain relief is limited. limited in its effectiveness.
• One could use the higher frequencies • It is suggested therefore, that in order to
(90-150 Hz) to stimulate the pain gate achieve these effects, suitable combina-
70 Handbook of Practical Electrotherapy

tions of muscle stimulation should be problem (as well as generating a range of

made. effects).
• The sweep (range) should be appropriate
Treatment Techniques to the desired physiological effects, though
• Preparation of the patient and the machine again it is suggested that an excessive
is done, as before any low frequency range may minimise the clinical effect.
electrical stimulation • The mode of delivery of the selected sweep
• The same local precautions, general varies with machines.
contraindications, environment and the • The most common application is the 6
safety considerations apply for IFT, as in second rise and fall between the pre-set
case of low frequency stimulation. frequencies.
• The IFT is usually applied through four • For example, if a 10 to 25 Hz range has
carbon rubber electrode plates between been selected, the machine will deliver a
5 and 15 sqcm in size. These are applied on changing frequency, starting at 10 Hz,
the prepared skin, with a coating of rising to 25 Hz over a 6 second period.
conductive electrode gel and fixed with Once this upper limit has been achieved,
elastic strap. the frequency will once again fall, over a 6
• Some IFT machines have built-in or second period to its starting point at 10 Hz.
optional vacuum suction pumps, for appli- This pattern is repeated throughout the
cation of vacuum cup electrodes, with moist treatment session
sponge fillers to maintain electrical contact
• Treatment times vary widely according to
with the skin. Fixing such electrodes is
the usual clinical parameters of acute/
easy, particularly over odd-shaped areas
chronic conditions and the type of physio-
like the shoulder joint.
logical effect desired.
• Electrode positioning should ensure
• In acute conditions, shorter treatment
adequate coverage of the area for stimu-
lation (Fig. 8.4, Plate 5) times of 5 to 10 minutes may be sufficient
• In some circumstances, a bipolar method to achieve the effect. In other circum-
is preferable if a longitudinal zone requires stances, it may be necessary to stimulate
stimulation rather than an isolated tissue the tissues for 20 to 30 minutes.
area. • It is suggested that short treatment times
• Placement of the electrodes should be such are initially adopted especially with the
that a crossover effect is achieved in the acute case in case of symptom exacer-
desired area. bation.
• If the electrodes are not placed so that a • These can be progressed if the aim has not
crossover is achieved, the physiological been achieved and no untoward side
effects of I/F cannot be achieved. effects have been produced.
• Nerves will accommodate to a constant • There is no research evidence to support
signal and, the continuous progression of a treatment
• A sweep (or gradually changing fre- dose in order to increase or maintain its
quency) is often used to overcome this effect.
 Medium Frequency Currents 71

TYPES OF INTERFERENTIAL CURRENTS

(FOUR POLE APPLICATION)
Classical Interference Current
• Interference occurs between two unmodu-
lated currents, crossing each other’s path
within the target tissue (Fig. 8.5, Plate 5)
• In this classical form of interference
current, modulation depth is 0 per cent at
the axis of two electrodes of pole. In this
direction no stimulation takes place.
• 100 per cent modulation takes place only
at a diagonal, creating a field of sti-
mulation perpendicular to the lines of
forces between two electrodes of a single
pole.
• Since the lines of forces of two poles are
crossed within the tissues, a four armed
(chatuevuj) field is generated. This type of Fig. 8.6: Clover leaf pattern of electrical field in IFT
pattern is called the Clover Leaf Pattern
(Fig. 8.6)
• The effect of this type of field produced
by four pole application is very dependant
on the direction of electrode placement
and the resultant field.
• It is vital to position the crossing area of
the currents at the correct location to
ensure the accurate alignment of the field
of 100 per cent stimulation, with the target
tissue.
• Since the stimulation is optimal only in
two directions, the position of the four
Fig. 8.7:
electrodes must be done with great care. Isoplaner vector
• Fine tuning of the spread of stimulation field application
can be done with the balance control. It to the knee joint
works like the balance knob of a stereo-
phonic sound system. • Gives a stimulus, which is equal in all
directions instead of clover leaf pattern.
The Clover Leaf Pattern • The depth of modulation is 100 per cent
Isoplaner Vector Field and the current is same in all directions,
making sure that all tissue between the
• Applied through four electrodes like four electrodes will receive effective
classical interference current (Fig. 8.7). treatment.
72 Handbook of Practical Electrotherapy

• Suitable for large joints like the knee,

particularly when swollen and when the
complaint is diffuse and hard to localize.
• Because of the mildness of isoplaner field
stimulation, it is best suited for acute con-
ditions like sciatica (Fig. 8.10).

Dipole Vector Field

• Though applied through four electrodes,
the distribution of current in one direction
is 100 per cent and the other is 0 per cent.
• This enables the current to be applied
Fig. 8.10: Placement of electrodes for application
selectively to a specific area through static of IFT to the sciatic root
vector mode or rotate the field like the
lights of a lighthouse, stimulating tissues muscled areas like painful shoulder, low
cyclically in all directions between the four back pain and, pain of the thighs etc
electrodes, in a dynamic vector mode. (Figs 8.8A and B and 8.9, Plate 5).
• The static vector mode is most useful in
case of longitudinal structures, e.g. bra- Two pole Medium Frequency Current
chioradialis or rectus femoris muscles. A • This type of current gives the same type
band of maximum intensity may be set up of stimulation as compared to four pole
between the poles of the electrodes to interferential method
target a specific structure along its entire • Current modulation depth is 100 per cent
length, avoiding unnecessary stimulation in all direction. Maximum stimulation is
of adjacent structures. produced in the tissues lying between the
• The dynamic vector has deionising effect electrodes, along the lines of forces con-
on acute muscle spasm of large muscular necticting the electrodes and 0 per cent
areas because of the massaging effect it perpendicular to the lines of forces.
creates and its soothing nature of stimu- • Application is simpler due to less number
lation. of electrodes, though in depth effect is
• Cyclic contraction and relaxation creates comparable to the four-pole method.
pumping in muscles, increasing venous • Suitable for localized smaller areas like the
drainage, reducing oedema, and improv- temporomandibular joints, muscles of the
ing blood circulation. hand, paracervical muscles, etc. It is
• This type of current is most suitable for the specifically used to achieve relief of pain
treatment of muscle spasm of heavily in sciatic neuralgia.
 Medium Frequency Currents 73

Clinical Applications of Interferential Current

Disease condition Type of current Current parameter Electrode placement

Tension headache Dipole vector field AMF-100 Hz, Crossed 4 pole, 2 each
Autosweep-3 sec over the origin and
Contour-40%, insertion of bilateral
Dose-15 minutes Trapezius muscle upper
fibres, strong tingling felt
Periarthritis of Dipole vector field AMF-100 Hz Crossed 4 pole method
shoulder, with Spectrum-50 Hz, Channel A Anterior-
generalized pain and Manual sweep posterior of shoulder,
spasm around the Contour-40%, Channel B over deltoid
joint and restriction Dose-15 minutes tubercle and acromion
of ROM at end range arch, light rhythmic
contraction seen
(Fig. 8.8A, Plate 5)
Periarthritis of 2 Pole medium AMF-100 Hz 2 Poles of a single
shoulder, with Frequency field Spectrum-50 Hz, channel, AP placement
localized tenderness Manual sweep-3 sec across the shoulder
and no significant Contour-40%, covering the tender spot,
restriction of ROM Dose-15 minutes light rhythmic contrac-
tion seen
Frozen shoulder or a. Isoplaner vector field a. AMF-100 Hz; 1 min. Crossed 4 pole method
adhesive capsulitis, b. Dipole vector field b. AMF-100 Hz, Channel A Anterior-
with gross restriction Autosweep-3 sec posterior of shoulder,
of ROM and night Contour-40%, Channel B over deltoid
pain, especially in Dose-12 minutes tubercle and acromion
diabetics arch, light rhythmic
contraction seen
(Fig. 8.8A, Plate 5)
Peripheral oedema Isoplaner vector field AMF-50 Hz Crossed 4 pole method
of transudate type Spectrum-50 Hz, Cover the entire oedema,
Manual sweep-1 sec elevate the limb,
Contour-01%, strong vibration felt
Dose-10 minutes
Lumbago a. Isoplaner vector field a. AMF-200 Hz; 2 min. Crossed 4 pole method
b. Dipole vector field b. AMF-100 Hz, Electrodes placed on
Autosweep-3 sec either side of the vertebral
Contour-40%, column covering the
Dose-12 minutes muscle painful region,
light rhythmic contrac-
tion seen (Fig. 8.4, Plate 5)
Muscle contusion Dipole vector field AMF-100 Hz, Crossed 4 pole method
Autosweep-3 sec Cover the entire lesion
Contour-40%, support the limb, light
Dose-07 minutes rhythmic contraction seen
(Fig. 8.9, Plate 5)

Contd....
74 Handbook of Practical Electrotherapy

Contd...

Disease condition Type of current Current parameter Electrode placement

OA hip joint Isoplaner vector field AMF-50 Hz Crossed 4 pole method

Spectrum-50 Hz, Channel A Anterior-
Sweep-6 sec posterior of the hip,
Contour-67%, Channel B dorsal to
Dose-15 minutes greater trochanter and
the groin, light rhythmic
contraction seen
Tennis elbow or 2 Pole medium AMF-80 Hz 2 Poles of a single
Golfer’s elbow Frequency field Spectrum-40 Hz, channel, mediolateral
Manual sweep-3 sec placement across the
Contour-75%, elbow covering the tender
Dose-10 minutes spot, light rhythmic
contraction seen
Weakness of Dipole vector field AMF-30 Hz, Crossed 4 pole method
abdominal muscles Autosweep-5 sec Electrodes placed on
Contour-0%, either side of the midline
Dose-15 minutes covering the muscles,
light rhythmic contraction
seen
Post immobilization Isoplaner vector field AMF-25 Hz Crossed 4 pole method
contractures of large Spectrum-10 Hz, Electrodes placed on
joints Sweep-2 sec either side covering the
Contour-10%, joint, light rhythmic
Dose-15 minutes contraction felt (Fig. 8.7)
Post immobilization 2 Pole medium AMF-25 Hz Trans-arthral 2 pole
contractures of small frequency field Spectrum-10 Hz, method
joints Sweep-2 sec Electrodes placed on
Contour-10%, either side covering the
Dose-10 minutes joint, deep stimulation
felt
Atonic bladder Classical interferential AMF- 1 Hz Crossed 4 pole,
current Spectrum-99 Hz, 2 large electrodes over the
Sweep-3 sec buttock just lateral to the
Contour-50%, SI joint and 2 smaller
Dose-10 minutes electrodes on either side
just above the symphysis
pubis, strong tingling felt.
Myalgia of large Dipole vector field AMF-100 Hz, Crossed 4 pole, electrodes
muscle groups Autosweep-2 sec covering the whole
Contour-40%, muscle group, along with
Dose-08 minutes the antagonists (Fig. 8.5,
Plate 5)
Myalgia of small Medium frequency AMF-100 Hz, 2 Electrodes over the
muscle groups surge currents Surge duration -3 sec muscle belly.

Contd....
 Medium Frequency Currents 75

Contd...

Disease condition Type of current Current parameter Electrode placement

Surge interval-3 sec Minimum perceptible

Contour 30% contraction.
Dose- 10 minutes
Haemoarthrosis of Isoplaner vector field AMF-80 Hz Crossed 4 pole method
knee joint (up to Spectrum-40 Hz, Channel A Anterior-
grade-II) Sweep-1 sec posterior of the joint,
Contour-10%, Channel B Medio-lateral
Dose-12 minutes to the joint, light
rhythmic contraction seen
(Fig. 8.5, Plate 5)
Tenosinovitis Medium frequency AMF-20 Hz 2 Pole: One over the
current Spectrum-100 Hz, muscle belly and one over
Sweep-1 sec the tendon.
Contour-1%, Definite alternating
Dose-17 minutes sensations felt.
Cellulites Dipole vector AMF- 50 Hz 4 Pole placement over
Sweep- 3 sec the affected area.
Dose- 15 minutes Clear rhythmical
contractions felt.
Rheumatoid arthritis Isoplanar vector field AMF- 100 Hz 4 Pole placement around
Spectrum- 50 Hz the affected joint (Fig. 8.7)
Sweep time- 3 Sec
Contour- 67 %
Dose- 10 minutes
Chronic constipation Classical interferential AMF- 20 Hz Crossed 4 pole method: 2
current Spectrum- 20 Hz electrodes placed on the
Sweep time- 4 sec abdominal wall, over the
Contour- 33% iliac fossa on either side:
Dose- 30 minutes other two placed under
the SI region.
76 Handbook of Practical Electrotherapy

9
Therapeutic Heat
Human body seeks warmth, particularly at NATURE OF THERAPEUTIC HEAT
the time of distress or while in pain.
Therapeutic heat can be used in two forms,
Since time immemorial, the humankind
superficial heat and deep heat. The classification
has used heat for various useful purposes,
is done on the basis of depth of penetration
especially for the treatment of aches and
of the thermal effect in to the body tissue. In
pains.
either kind of application the intensity of the
Before the discovery of fire, the primary
heat is first perceived by the thermal receptors
natural source of heat was the sun. The heat
present on the surface of the skin. Therefore
of the sun still remains a favourite among the
elderly population for giving relief to their the level of the heat should never exceed a
aching bones. This is the first ever application feeling of comfortable warmth, whether the
of therapeutic heat. mode of application is superficial or deep.
With the discovery of fire, mankind found
a new tool for their survival. Apart from SUPERFICIAL HEAT THERAPY
keeping predators away heat from the fire Superficial heat has a maximum depth of
helped cook food and keep them warm. penetration of 5 mm from the surface of the
Ancient healers used rocks, sand and salt skin. The effect is therefore restricted to the
packs heated on fire for treating many types skin and superficial subcutaneous tissues.
of painful disorders. Heated water also
provided an important source of therapeutic Transmission of Superficial Heat
heat.
The ancient Romans first introduced the Heating depends on transfer of heat energy
concept of heated mud packs, hot bath and from a point of higher concentration to a point
steam bath or sauna to treat muscular and of lower concentration. Such transmission of
skeletal rheumatism. heat energy can occur by three methods.
With the progress of science, newer 1. Conduction of heat: Heat energy transferred
methods of generating heat has been identi- from a warmer object to a cooler object by
fied, many of which have been adapted for direct transmission of molecular agitation
application to the human body to derive through physical contact, e.g. salt packs,
therapeutic benefits. moist packs, and paraffin wax bath.
 Therapeutic Heat 77

2. Convection of heat: Heat energy transferred

by movement from a warmer zone of fluid
or air to a cooler area by convection
current, resulting in indirect transmission
of molecular agitation through physical
movement of the molecules over the cooler
body part, e.g. whirl pool bath, warm
saline bath, hydrotherapy.
3. Radiation of heat: Heat energy transferred
from a warmer object to a cooler object by
electromagnetic radiation, without any
heating of the medium of heat transfer, e.g.
infrared radiation (Fig. 9.1).
Fig. 9.1: Position of the patient and the relative
position of the infrared lamp for application of
Physiological Effect of Superficial Heat superficial heat to the nape of the neck.
Superficial heat has different kinds of effects
depending on the nature of application. 2. Increased interstitial fluids turn
A. Generalized heating of large areas of the over and better drainage due to
body surface, like the entire upper or lower
higher capillary permeability.
limbs, whole back or whole body, with
3. Increased flexibility of capsules,
whirlpool bath, Hubbard’s tank or heated
ligaments and tendons due to grea-
hydrotherapy pool, produces following
ter elasticity of collagen fibres.
effects:
4. Increased metabolic rate due to
• Increased physiological reactions:
Raised cardiac output, metabolic rate, increase in cellular oxidation.
pulse rate, respiratory rate and super- b. Decreased physiological reactions:
ficial blood circulation due to dilatation 1. Decreased joint stiffness due to
of capillary network. greater flexibility of collagen tissue.
• Decreased physiological reactions: 2. Decreased muscle torque due to
Lowered blood pressure, muscle suppression of glycol breakdown.
spasm, blood supply to internal organs 3. Decreased muscle spasm due to
and muscles and stroke volume of the diminished neural activity.
heart. 4. Decreased pain due to pre-synaptic
B. Local heat application to small areas of inhibition of pain transmission.
the body, like the knee or shoulder joint,
neck, low back region, with infrared lamp, Indications for Superficial Heat
Paraffin wax bath, moist hot packs, electric
heating pads or hot water bags, produces Superficial heat is the modality of choice, to raise
following effects. the general or local temperature of the body
a. Increased physiological reactions: tissues, as a preparatory step before appli-
1. Increased local blood flow due to cation of active movements, passive mobi-
vasodilatation. lisation, massage or electrical stimulation to
78 Handbook of Practical Electrotherapy

the musculoskeletal system, particularly in • Position the patient comfortably so that

presence of: he/she can sustain the position for at least
• Joint stiffness and pain ½ hour.
• Muscle spasm and pain • Expose the part to be treated; rest of the
• Painful chronic lesions—Posttraumatic, body should be covered with a sheet.
degenerative or inflammatory • Check for rashes, cuts, bruises and dis-
coloration of the skin.
• Rheumatism of the skeletal and soft tissue.
• Test the thermal sensation of the skin. Take
two test tubes and fill either with hot or
Contraindications for Superficial Heat
cold water, beyond the sight of the patient.
• Acute traumatic and inflammatory lesions Place the test tubes by turn against the skin
of the musculoskeletal system and ask the patient to identify the type
• Infections—local or general sensation felt.
• Circulatory deficiency • Test the awareness level of the patient prior
• Diminished thermal sensation to application of thermotherapy. Heat
• Deep vein thrombosis therapy should be avoided in patients with
cognitive dysfunction, e.g. Alzheimer’s
• Malignancy
disease, multiple infarct dementia or
• Bleeding disorder
mental retardation.
• Severe swelling
• Make sure the patient understands the
• Impaired cognition or inability to assess nature and the extent of heat that should
the degree of heat being felt. be felt during the treatment. Explain the
• Very young and very old patients. possible adverse reactions of overheating,
because some patients may believe that
PREPARATION OF PATIENT BEFORE more heat means quicker relief. A call bell
APPLICATION OF HEAT OR COLD should be placed near the patient, to
THERAPY summon the therapist in case of over-
Application of thermal energy to the body heating or burning sensation during the
treatment.
carries the risk of thermal injury, usually to
• Inspect then part closely for any rashes,
the skin, sometimes affecting the deeper
blister formation or excessive reddening
tissues. The nature of injury varies with the
after the treatment. Calamine lotion may
intensity and duration of heat applied, the be applied over the reddened area or heat
colour and sensitivity of the skin, presence of rash and the subsequent sittings deferred
skin rashes or allergies on the area being till the skin becomes normal.
treated, sensory acuity or cognitive ability of Preparation of patient, delivery of treat-
the patient etc therefore, before application of ment and precautions to be observed in
any kind of thermal energy, heat or cold, thermotherapy are same for most forms of
adequate preparations must be done. superficial heat or deep heat or cold modali-
• Thermotherapy must be done personally ties. Specific modalities have few specific
or under direct supervision of a qualified concerns that need attention, covered under
therapist. the heading of ‘special points’.
 Therapeutic Heat 79

TYPES OF SUPERFICIAL 2. For large-sized packs—Fold two large

HEAT MODALITIES Turkish towels breadth wise in to eight
A number of superficial heat modalities are folds. Place one-folded towel over the
available for the therapist to use. These are area to be treated, usually covering the
hydrocollator, hydrotherapy, paraffin wax whole back and place the heated pack
bath and infrared therapy, which have been on it. Cover the pack with the other
detailed below. Infrared can be obtained from folded towel to prevent heat loss and
luminous (visible light) or non-luminous place a small sand bag on top to keep
sources, though its biophysics and effects are the pack in position. Extra towel layers
essentially the same. Thus for convenience of may be used if the heat is too much for
the reader, only the non-luminous variety has comfort.
been considered along with the basic bio- • Duration of treatment—20 to 30 minutes in
physics, under the section of superficial heat, a sitting may be repeated twice a day in
with the luminous variety detailed under the acute conditions.
section of therapeutic light in this volume. • Effective in—Superficial muscle spasm and
pain, inhibition and restriction of joint
Moist Hot Packs—Hydrocollator movement.
• Special points: Moist packs and towels are
Points to Ponder
a potential source for fungal growth. They
• Packs used are made of canvas, filled with must be dried thoroughly before reuse.
silica gel, which has the capacity to retain Wash all linen and packs in weak disinfec-
heat for long period of time. tant solution once a week.
• The packs are available ready made in large,
medium, small sizes, as well as for specialized HYDROTHERAPY FOR SUPERFICIAL
application of cervical region. HEATING—WHIRLPOOL BATH/
• The packs are placed in a double-walled HUBBARD’S TANK/SAUNA
stainless steel tank, containing hot water at
50 to 60° C, heated electrically and regula- History
ted by a thermostat. The origin of hydrotherapy can be traced back
• Method of heating—Conduction of heat to ancient times, when soaking in natural hot
from hot water to silica gel. springs were favoured by traditional healers
• Method of application— for treatment of all forms of joint disorders.
1. For small and medium-sized packs—Fold Ayurvedas and Charka Samhita has number of
a large Turkish towel lengthwise into references to the therapeutic application of
four folds. Wrap the folded towel whole body submersion in hot springs, as well
around the heated pack so that both as, cold water baths. Ancient Chinese and
side of the pack has eight layers of Arabs also used hydrotherapy as a method
towel cover. Place the pack over the of treatment in the years B.C. Ancient Roman
area to be treated, e.g. knee, elbow, and Turkish physicians popularized the
wrist or shoulder joint and secure it in concept of public bath houses, with pools
position with a strap. having variety of water temperatures, with
80 Handbook of Practical Electrotherapy

add on services like massage, steam bath or submersion of a body in water (Archi-
sauna, for treatment of stress and musculo- medes principle), renders the limb or body
skeletal disorders. These bath houses soon weightless making it easy for the patient
became popular meeting ground for the to move a weak limb actively or allow him
common man and the ruling elite. to stand and walk on weakened legs.
In medieval Europe painful joint disorders • The capacity of water to absorb heat is
were clubbed together as rheumatism. These known as specific heat, which the amount
were referred for treatment to health centres of heat needed to raise the temperature of
known as ‘Spa’ located close to natural hot 1 gram of water by 1°C. The heat from the
springs. Over time these places developed water is transferred to the body by means
into tourist attractions. Treatment in such
of convection giving relief from pain,
‘Spas’ were outrageously expensive and could
muscle spasm and stiffness.
be afforded by only the elite of the society.
• Modern hydrotherapy utilizes three
Many such ‘Spas’ are still to be found in
modes of superficial heat application:
countries like Germany, Austria, Italy, Russia,
Whirlpool bath, Hubbard’s tank and steam
as well as, in India. The mode of treatment
followed in such naturopathy centres are bath or sauna.
based on regular soaking of the entire body
Method of Application of Whirlpool Bath
of the patient in the mineral rich water of the
hot springs, supplemented by a natural diet, A. Whirlpool bath is immersion of an extre-
massage and exercises. They are still as mity in a pool of circulating heated water,
expensive. suitable for treatment of the extremities
With the western medical science becom- only. It is widely used for heating of soft
ing more cosmopolitan and oriented to the tissue around joints prior to mobilisation
service of common man, methods were or debridement and disinfection of burn
devised to provide the beneficial effects of the wounds.
‘Spa’ in a general hospital setting, with B. Whirlpool bath consists of a oblong-sha-
proportionate reduction in cost of treatment. ped stainless steel tank, usually 3’deep x
This is how modern hydrotherapy was born 3’long x 2’wide in size, mounted on four
in mid 19th century in England, soon to be castor wheels, fitted with a thermostat-
adopted by the entire Europe and the World. controlled, immersion type electric heating
coil and an air-jet pump with nozzle.
Points to Ponder C. The tank is filled with water, leaving a gap
• Definition: Hydrotherapy can be defined as of 6’ to 8’ from the top. The water is heated
partial or total submersion of the body in to 35° to 40°C. A disposable plastic liner
water baths or pools, where the water may may be used and any common disinfec-
be agitated or mixed with air, to be tants like sodium hypochlorite at dilution
directed as jets, against or around the part of 200 parts per million (ppm), povidone-
to be treated. iodine at 4 ppm or savlon at 100 ppm may
• The buoyancy of water, an upward thrust be added while treating burn injuries and
equal to the weight of water displaced by infected wounds.
 Therapeutic Heat 81

D. The patient is assisted to immerse the body liner may be used and disinfectants be
part in the tank, after sitting down comfor- added if a burn patient is to be treated.
tably on a height-adjustable stool placed D. The patient, if ambulatory, may be helped
beside the tank. to climb in the tank, using a metal step
E. Adjust the direction and force of the air- stool. Mostly they are transferred into the
jet to get the desired effect, which may be tank using a nylon sling and bed side hoist.
to offer resistance or assistance to active The patient should be lowered gradually
movement or debridement (peeling off) of into the tank to allow him to get accusto-
dead tissues from the surface of a wound. med to the water temperature.
Most patients, including those with severe E. Care should be taken to keep the head of
the patient out of water. This may be done
burns, find the whirlpool bath very
using an inflatable neck ring and a head
soothing.
support. The rest of the body may be
F. The duration of treatment is usually 20 to
allowed to float free in the circulating
30 min. After the treatment the part should
water of the tank.
be dried and inspected closely for any
F. Adjust the direction and force of the air jet
adverse reaction from heat.
to get the desired effect, which may be to
induce relief of pain or relaxation in spastic
Method of Application of Hubbard’s Tank
muscle prior to exercises or debridement
A. Hubbard’s tank is immersion of the whole (peeling off) of dead tissues from the
body in a pool of circulating heated water, surface of a wound. Most patients, includ-
suitable for the treatment of acute or sub- ing those with severe burns, find tanking
acute rheumatoid arthritis presenting with very soothing.
multiple joint pains, whole body burn G. The duration of treatment is usually
injury and paraplegia. It is ideal for 20 to 30 min. After the treatment the part
treatment of very ill-patients in unstable should be dried and inspected closely for
condition, with severe pain or serious any adverse reaction from heat.
infections, as in extensive burn, since the Special Points to Ponder
patient can be treated with whole body
• Since immersion type heating elements are
immersion, in an isolated environment.
used, electrical safety of the patient must
B. Hubbard’s tank consists of a butterfly-
be ensured at all times, because in case of
shaped steel tank having a depth of 3’ and
any leakage of current, it is likely to flow
large enough to accommodate the entire
through the body of the patient, to the
body of the patient, fitted with two
ground.
thermostat-controlled, immersion type
• All electrical components like the heating
electric heating coils and two air-jet pump element; thermostat, turbine etc must be
with nozzles at either end of the tank. checked weekly to prevent any leakage of
C. The tank is filled with water to the desired current and earth fault.
level (see whirlpool), which is then heated • All circuits must have properly calibrated
to the desired temperature. A disposable circuit breakers.
82 Handbook of Practical Electrotherapy

Method of Application of water the patient drinks after the treat-

Steam Bath or Sauna ment.
Traditional sauna, used in Scandinavian
Special Points to Ponder
countries, Turkey and Russia, as a public
utility service, consists of a sealed room, lined • Dehydration is a major risk in steam bath.
with wood panels for insulation, with a coal Patients with chronic dehydration, like the
burning stove with a metal jacket, in the centre elderly, must be given sauna with caution.
of the room. Water is poured on the heated All patients must be encouraged to drink
metal jacket to generate steam. Clients sit electrolyte-balanced drinks before and
around on wooden benches surrounding the after the therapy.
stove and enjoy the effects of steam. • Patients with hypertension and heart
• The steam bath as used in modern hydro- diseases must not be given sauna because
therapy consists of an insulated chamber of adverse physiological responses pro-
made of laminated waterproof ply wood duced by prolonged exposure to heat and
or man made fibres, large enough accom- excessive sweating.
modate a person in sitting position.
• The patient is asked to strip and a towel PARAFFIN WAX BATH
used for preserving the modesty. Total
• Paraffin wax bath is the therapeutic appli-
privacy is essential for this form of
treatment, so that the patient can relax cation of molten mixture of paraffin wax
during the treatment. A female therapist and mineral oils, for relief of pain and joint
or a female attendant must treat female stiffness, suitable for peripheral joints like
patients. small joints of hands and feet, ankle, knee
• The chamber is sealed air-tight, leaving the and elbow joints
head of the patient seated inside, through • The paraffin wax bath consists of a double
a head port. walled insulated stainless steel bath, 24”×
• Steam is fed into the chamber from a boiler 12”× 8”in size, heated indirectly by heating
situated outside the chamber. coil.
• Approximate temperature within the • The mixture of paraffin wax, liquid
chamber is maintained at 40° to 45°C. paraffin and petroleum jelly, in a ratio of
• The patient is instructed to call the 3:1:1, melts at 42 to 45°C and is self-steri-
therapist in case of any discomfort. A call lizing in nature. The temperature is sus-
bell may be provided for this purpose. tained by thermostat-controlled heating.
• Treatment sessions can be for 20 to 30 • Molten wax mixture solidifies on contact
minutes. with the skin, giving up latent heat of
• Physiological effects are same as that solidification, which is transferred to the
produced by generalized heating. body by conduction.
• Therapeutic benefits are relief of stress,
muscle spasm, pains and aches. Claims of Method of Application
reduction in body weight, as a major effect • All jewellery and metal object must be
of sauna, is mostly temporary due to loss removed from the part to be treated.
of water from the body due to sweating, • The part should be washed and checked
which is made up with few glasses of for any infection, rash or bruises.
 Therapeutic Heat 83

• The part is repeatedly dipped in the directly proportional to the extent of

molten wax mixture, as for hands and feet radiation absorbed. Optimal absorp-
or the molten mixture is poured over the tion is possible only when the source
part, as for wrist, ankle, knee and elbow, of radiation is perpendicular to skin.
to form ten successive layer of wax b. Inverse square law, which states that the
coating. intensity of radiation varies inversely
• The coated part is then wrapped with a with the square of the distance between
polyethylene sheet, followed by few layers the source of radiation and the skin.
of towel to retain the heat. Intensity of the radiation is reduced if
• The part is then placed in a comfortable the distance between the source and the
position till the feeling of heat ceases. The target is increased and vice versa.
solid mixture peels off after cooling and
can be reused again in the wax bath. Method of Application
• Physiological effects are same as that • The non-luminous lamp is turned on
produced by localized heating. approximately 5-10 minutes before appli-
• Therapeutic benefits are relief of reduction cation to ensure maximum output.
of pain and joint stiffness, which can be • Expose and support the part to be treated
used prior to passive movements and examine the skin as detailed in general
preparatory methods.
RADIANT HEAT–INFRARED RAYS • Give the patient a glass of water before and
after the treatment.
• Radiant heat is the therapeutic application • After positioning the patient comfortably,
of radiant electromagnetic energy, obtai- cover the eyes and avert the face from the
ned either as invisible infrared from any source of infrared.
heat source or in combination with visible • Commence the treatment with the I.R
light and ultraviolet rays from an incan- source placed at a distance of 30” to
descent electric bulb or sunlight. 36”from the surface being treated (Fig. 9.2).
• In this section only the non-luminous • The dosage can be adjusted by shifting the
infrared has been considered since it is a source closer or away from the treatment
superficial heat modality. The luminous surface, depending on the feeling of
infrared has been covered under the warmth by the patient. The feedback of the
section of therapeutic light. patient is absolutely essential to adjust the
• Non-luminous infrared contains far infra- dose, hence the patient must explained in
red electromagnetic rays in the frequency detail about the expected heat sensation.
range of 1500 to 12000 Angstrom units, This is done by asking the patient to blow
having a penetration of 2 mm in the epi- on the back of his hand, holding it close to
dermis. the mouth. The amount of heat felt on the
• Heat transmission with infrared radiation dorsum will be the optimum limit of
is governed by following physical prin- warmth to be felt on the skin, with any
ciples: form of heat therapy.
a. Lambert’s cosine law, which states that • Duration of treatment should be 15 to 20
the angle incidence of radiation is minutes once or twice a day.
84 Handbook of Practical Electrotherapy

Fig. 9.2: The arrangement of the lamp and the position

of the patient should be such that the incident rays are
perpendicular to the skin. The intensity of the superficial
heat can be increased or decreased by moving the lamp
closer or away from the skin. The minimum distance
between the source of infrared and the skin should be
50 cm

COMPARATIVE PROFILE OF SUPERFICIAL HEAT MODALITIES

Modality Most commonly used for Advantages Disadvantages

Moist heat Muscle spasm, pain and • Reusable and cost • Initially expensive,
stiffness of major joints of the effective • Risk of scalds
extremities, neck and trunk • Safe for delicate skin, • Risk of fungal
• Prolonged analgesia, infections
• Circumferential heating.
Infrared Superficial muscle spasm • Easy to apply • Risk of burn if source
and localized pain of neck • Better localization of heat. is too close to the skin
and trunk • Cost effective for home • Risk of eye injury in
management luminous I.R
• Effect is transient
Paraffin wax Stiffness of joints and pain • Circumferential heating, • Messy application
bath due to degenerative disorders, • Improves the texture of procedure,
Soft tissues contractures the skin • Regulation of tempera-
following immobilisation • Increases pliability of ture difficult and may
soft tissue cause burn,
• Prolonged analgesia. • Highly inflammable
• Reusable and cost composition, hence fire
effective hazard
Whirl pool/ Multiple joint stiffness and • Applicable for whole or • Expensive to install
Hubbard’s tank pain, disuse atrophy, wound part of the body and run
debridement in burn, paralytic • Induces relaxation, relief • Needs more space
conditions of pain and spasm • Extensive preparation
• Exercise can be done and constant super-
easily due to buoyancy vision needed
• Messy operation
• Risk of electrical
accidents
 10
Deep Heat Therapy
Heat can be generated deep inside living living tissues, with clear physiological effects
tissues by conversion of non-thermal energy and therapeutic benefits.
like electromagnetic radiations and sound
absorbed by the body tissue, in to thermal Biophysics of Deep Heating
energy. This conversion of non-thermal energy Using Short-Wave Diathermy
into heat energy is achieved using the Heating with SWD is achieved by two
interaction between the non-thermal energy methods:
fields and the physical properties of the body a. Capacitor or condenser field method
tissues, namely capacitance, inductance and b. Inductance or magnetic field method.
acoustic impedance. Different modalities
using such energy conversion are short- Capacitor or Condenser Field
wave—diathermy, microwave diathermy and Method of Application
therapeutic ultrasound.
• Two electrodes, consisting of flexible metal
SHORT-WAVE DIATHERMY (SWD) plates encased in heat resistant rubber or
air-spaced drums, are connected to the
Definition output terminals of the high frequency
• Short-wave diathermy is the commonest current generator. The metal plates act as
deep heat modality used in physiotherapy the plates of a condenser, bearing + and –
departments in India. It utilises high charge.
frequency alternating sinusoidal current at • The charge of the electrodes keeps oscillat-
frequency of 27.12 MHz to produce electro- ing at a high frequency of 27.12 MHz,
magnetic (Radiowaves) with wavelength of producing a powerful electromagnetic
11.3 meters. This wavelength and the field between the two electrodes.
frequency are reserved for therapeutic • This field of energy is conventionally
purpose by International agreement, to described as the lines of forces, which are
avoid interference with other radio- imaginary lines connecting the opposing
frequencies and communication network. faces of the electrode plates.
• When subjected to the electromagnetic field • Body tissues placed between the two
generated by the SWD, heat is produced in electrodes, become a part of the condenser
86 Handbook of Practical Electrotherapy

circuit, as a di-electric medium, and are terminals of the high frequency current
subjected to these lines of forces. generator.
• High frequency oscillating current pro- • High frequency oscillating current produ-
duces rapid oscillation of the ions, rotation ces an electromagnetic field around the
of the dipoles and distortion of insulators conductor.
present at the molecular level of the living • The cable is coiled around the body part
tissues. to be treated.
• This activity at the molecular level of the • The hinged drum is placed over the body
living tissue produces displacement part, without actually being in contact
current in tissues with high electrical with the body surface.
resistance and conduction current in • Through electromagnetic induction, secon-
tissues with low electrical resistance. dary Eddy current is induced in the body
• Resistance to the passage of current deep tissue placed within the electromagnetic
within the tissues produces heat. field, though it is not a part of the circuit.
• Dense tissues with closely-packed mole- • Resistance to the passage of Eddy current
cules like the skin, fat, fascia, ligament etc produces maximum heat in deep tissues
offer greater resistance to the passage of with high electrolyte concentration,
the electrical field and become warmer,
particularly in tissues with high conduc-
than loosely-packed tissues like muscles
tivity like blood, nerves and muscles.
and blood.
• Dissipation of heat is much slower and the
• Subcutaneous fat is an insulator and
effect of heating tends to be prolonged.
therefore the layer of fat absorbs much of
the lines of forces. Production of High Frequency Current
• Though technically the condenser field
method should be effective for through The machine circuit–Consists primarily of the
and through heating, in reality little heat high frequency current generator, with three
reaches to layer deeper than the subcuta- controls on the faceplate of the device. The
neous fat. intensity knob is a rotary step switch that
• This type of application is therefore most controls the amplitude of the high frequency
effective when the target tissues do not current and is a part of the machine circuit,
have a thick layer of fat covering. the tuning knob is a constantly variable rotary
• Intensity of heating and depth of pene- switch attached to a variable condenser and
tration are determined by the shape and is a part of the patient circuit and auto cut-off
the distance between the electrodes. timer to set the duration of treatment and stop
the flow of high frequency current to the
Inductance or Magnetic Field
patient circuit on completion of the treatment
Method of Application
duration. It may be either a digital or
• An insulated monoaxial cable or hinged analogue stopwatch (Figs. 10.1 and 10.2).
plastic drums each containing a coil of • The patient circuit – The variable conden-
conductor, is connected to the output ser, electrode connecting cables, electrodes
 Deep Heat Therapy 87

Fig. 10.2: The circuit configuration of the high-

frequency AC link DC-DC converter using secondary
phase-shifted PWM control scheme (below called
“proposed control scheme”) is shown in Fig.1. This
circuit is composed of the high-frequency inverter, the
high-frequency transformer, the diode rectifier circuit
and the LC filter. A difference between conventional
DC-DC converter and proposed DC-DC converter is
two power devices are newly connected inside the
diode rectifier circuit. Fig.2 shows its switching pattern,
inverter output voltage waveform and output current
waveform. In conventional control scheme, the
converter output voltage was controlled by giving
phase-difference between the right and left arms of
the full-bridge inverter on the primary side. In
proposed control scheme, the converter output
voltage is controlled by giving phase-difference
between the primary side and the secondary side,
which is synchronized with the primary side. From this
reason, between the right and left arms of the full-
bridge inverter does not have phase-difference.
Namely, it operates as a square-wave generator like
a symmetrical drive with 50% duty including dead
time. By using proposed control scheme, secondary
switches S5 and S6 are both off during the circulation
interval (t1 < t < t2) in which the power is not supplied
form the primary side. At this point, the circulating
current will flow only the secondary circuits via the
high-frequency transformer. Therefore, the circulating
current cannot flow on the primary side (this state is
called “the self circulation interval”). As a result, almost
conduction losses are eliminated because circulating
current can be removed. This is the distinctive feature
of proposed control scheme. In addition to this, all
power devices can operate under soft-switching
condition, independent of changing load resistance.
From these reasons, the conversion efficiency
become high compared with conventional DC-DC
converter because proposed control scheme can
Fig. 10.1: Short-wave diathermy unit effectively solve the problems mentioned above
88 Handbook of Practical Electrotherapy

and the body part which act as the dielec- generalized change in the body. These
tric of the variable condenser. changes are as follows:
• Transfer of energy—Maximum transfer of • Increased physiological reactions: Raised
energy from the machine circuit to the Cardiac output, metabolic rate, pulse rate,
patient circuit takes place when the respiratory rate, and generalized vasodila-
product of the capacitance and the induc- tation.
tance in both the machine and patient • Decreased physiological reactions: Low-
circuits match perfectly or said to Resonate. ered blood pressure, stroke volume and
• This is resonance of two circuits, is called blood supply to internal organs.
tuning and it is conventionally achieved by
rotating the tuning knob of the variable Local Physiological Effects and
condenser, like tuning an old-fashioned Therapeutic Benefits of Deep
radio. Heating with SWD
• The patient’s body acts as a part of the
variable condenser setup, till the product SWD application to specific areas of the body like
of the capacitance and the inductance in the knee joint, shoulder joint, neck, lumbo-
both circuits match. sacral region produces following local effects,
• Most modern SWD machines have auto- which have significant therapeutic value.
matic tuning, where the machine circuit Increased reactions
automatically searches for and finds 1. Increased local blood flow due to vaso-
resonance with the patient circuit, like the dilatation, leads to tissue healing, relief of
push button car radio. muscle spasm and pain.
• The tuning may be indicated by a neon 2. Increased interstitial fluids turn over and
tube tuning lamp, which glows brightest
better drainage due to higher capillary
at the point of maximum resonance
permeability, leads to reduction of swell-
between the two circuits.
ing.
• It may also be an ammeter, the needle of
3. Increased flexibility of capsules, ligaments
which shows maximum deflection on
and tendons due to greater elasticity of
tuning of the circuit.
collagen fibres lead to greater mobility of
PHYSIOLOGICAL EFFECTS OF joints.
SHORT-WAVE DIATHERMY 4. Increased metabolic rate leads to activation
of dormant tissue.
Deep heating produces physiological effects 5. Increased pain threshold due to sedation
that are similar to those produced by super-
of the pain carrying nerve fibres resulting
ficial heat, but its effects are spread much
in pain relief.
wider and deeper in the body tissue.
General physiological changes produced Decreased reactions
by deep heating with SWD. 1. Decreased joint stiffness due to greater
Adequate heating of the blood pool is pro- flexibility of collagen tissue.
duced on exposure to SWD for 15 to 30 2. Decreased muscle torque due to suppres-
minutes, which produces significant sion of glycol breakdown.
 Deep Heat Therapy 89

3. Decreased muscle spasm due to dimini- • Bleeding disorder

shed neural activity. • Severe swelling
4. Decreased pain due to pre-synaptic inhibi- • Impaired cognition or inability to assess
tion of pain transmission. the degree of heat being felt.
• Very young and very old patients.
INDICATIONS FOR SHORT-WAVE
DIATHERMY METHODS OF APPLICATION OF
SHORT-WAVE DIATHERMY
SWD is effective in management of pain and
inflammation associated with the following Preparation of the Equipment
disorders:
• The equipment is connected to the mains
• Musculoskeletal system disorders, e.g.
• The electrodes/cable are attached to the
spondylosis, osteoarthritis, rheumatoid
output terminal of the machine.
arthritis, degenerative joint diseases and
• The equipment is turned on and warmed
postural or posttraumatic muscle spasm
up for at least 2 minutes.
and pain.
• The therapist places one hand between the
• Pelvic inflammatory disorders, e.g. pelvic
electrode plates/over the coil of the cable
endometriosis.
electrode, increases the intensity at least
• Inflammation of body cavities, e.g. Sinu-
two steps from the minimum. The machine
sitis.
is then tuned by turning the tuning knob
• Using non-thermal effect of pulsed SWD
in one direction till maximum deflection
for healing of wounds. shows on the tuning meter. A comfortable
warmth should be felt after a minute or
CONTRAINDICATIONS OF
so, indicating that the machine output is
SHORT-WAVE DIATHERMY
adequate for treatment and it’s safe for
SWD should not be applied in following patient application.
conditions: • After testing the machine output the
• Presence of metal implants or ornaments intensity is returned to zero level and hand
within the field of the lines of forces. removed from the electrodes.
• Patients with pace-maker
• Pregnant women should not be given Application of Treatment with
SWD in the region of low-back or lower Short-Wave Diathermy
abdomen. • The patient is positioned in a comfortable
• Acute traumatic and inflammatory lesions position on a wooden plinth, part exposed
of the musculoskeletal system and the rest of the body draped with a
• Infections—local or general sheet.
• Circulatory deficiency • The part may be wrapped double layer of
• Diminished thermal sensation Turkish towel to absorb sweat produced
• Deep vein thrombosis during the treatment and acts as spacer
• Malignancy with air-space.
90 Handbook of Practical Electrotherapy

What are Spacers? or induction field method, as well as the area

• Spacers are insulating material containing air- to be treated and the effect desired from deep
spaces, like perforated felt pads or Turkish heat therapy.
towels applied in two or more layers
between the pad electrodes and the skin CONDENSER FIELD METHOD
surface. The spacers increase the distance SHORT-WAVE DIATHERMY
between the electrode surface and the skin to The condenser type electrodes may be, either
ensure an even distribution of the lines of pads made of flexible metal plates covered
forces and therefore the effect of the with a layer of heat resistant rubber or air-
heating. For optimum heating, the sum spaced drums electrodes. These are available
total of the thickness of the spacers must
in different sizes, from 4”× 6” up to 10” × 12”
be less than the distance between the pad
and may be round, square, rectangular or
electrodes, if kept side by side
butterfly-shaped for application to the
• Drum or disk electrodes used in condenser
maxillary and frontal sinuses. The electrodes
field method of application have a hard
are connected to the output terminal of the
plastic shell covering the metal disk
high frequency current generator through
conductor. The air-space within the plastic
shell is used as spacer, which can be varied, insulated co-axial cables. SWD Machines
by sliding the metal disk mounted on a usually have separate output sockets for
telescoping stalk, within the plastic shell. drum/pad/cable type electrodes. Perforated
(Fig. 10.3). felt pad spacers are placed on either side of
the pad electrodes and the whole complex is
ELECTRODE PLACEMENT enclosed in a cotton cloth envelope. Extra-
SHORT-WAVE DIATHERMY spacing, if required, may be provided by
using several layers of Turkish towel or extra-
The electrodes placement varies depending
felt pad spacers. Before application of elect-
on the type of application, i.e. condenser field
rodes, all clothing must be removed and the
part must be wrapped in at least one layer of
clean Turkish towel. This towel layer is
recommended for hygienic purpose, as well
as, to absorb any sweat that form while
heating the part (Figs 10.4 and 10.5, Plate 6).
a. Contraplaner placement: This is the prefer-
red method for treating joints like the knee
or elbow or shoulder joints using SWD.
The electrodes are placed on either sides
of the joint, on opposite planes, preferable
on a regular surface, without any bony
Fig. 10.3: Disc electrodes used in SWD. The outer prominence underneath the electrodes.
plastic shell has been removed to show the metal
discs within Bony prominences create concentration of
 Deep Heat Therapy 91

lines of forces, which may lead to burn. • For hip joint: (Figs 10.9 and 10.10,
The electrodes are held in position with a Plate 7).
Velcro strap (Fig. 10.6, Plate 6).
b. Coplaner placement: This is the method of CABLE METHOD SHORT-WAVE
DIATHERMY
choice for treating large, flat areas like the
back, using SWD. The electrodes are • The cable electrode consists of flexible co-axial
placed side by side on the same plane, conductor, enclosed in a sheath of heat
covering the entire treatment area (Figs resistant rubber.
10.7, Plate 6, and 10.8, Plate 7). • The length of a cable electrode is 1.5 meter.
c. Cross-fire placement: This method of elect- • Two metal jacks are attached to either ends
rode placement combines the effect of two of the cable, which are inserted in to the
contraplaner placements, to heat a large output sockets of the machine, specifically
earmarked for cable diathermy
joint like the knee, from all directions. The
• The arrangement of the cable in relation to
electrodes are first placed on the medial
the body part depends on the relative
and lateral aspects of the joint and heat
density of high or low impedance tissues
applied for half of the total treatment time.
present in the part to be treated.
Then the electrodes are shifted to superior • The cable can be applied either by wrapp-
and inferior aspect of the joint and heat ing it around the part to be treated like the
applied for the remaining duration. This extremities or in the form of a concentric
way the joint is heated thoroughly from coil placed over flat areas like the back or
all directions. This is the method of choice abdomen.
for treatment of chronic synovitis, when • The ends of the cable have greater concen-
the entire joint must be heated uniformly. tration of electrostatic forces which produces
d. Asymmetrical placement: These are speciali- more heat in high impedance tissues like
zed technique of application of SWD for skin, fat, fascia, tendon, ligaments, joint
preferential heating of heavily-muscled capsules etc. For treatment of parts like
areas like the calf or deep-seated joints like hand, wrist and distal forearm or foot,
the hip. ankle and lower leg or joints like the knee
• For calf muscles: Patient is placed in high or elbow, the outer 1/3 of the cable on either
sitting on a wooden plinth, with the feet side is used.
placed on a wooden stool. One pad • The middle 1/3 of the cable generates a
electrode is placed under the sole of the strong electromagnetic induction field, which
foot and the other on the top of the have greater effect on the low impedance
flexed knee. With this method, the lines tissues like muscles and blood vessels.
of forces pass parallel through the calf Hence the segment can be used heavily-
and leg muscles, producing maximum muscled and highly vascular areas like the
beneficial effect of electromagnetic field calf, thigh, upper arm etc.
in the muscles themselves, which is
most useful in anterior-lateral compart- APPLICATION OF TREATMENT WITH
ment syndrome or chronic spasm of SHORT-WAVE DIATHERMY
calf muscles or as a preparatory step • After the machine circuit has been warmed
before stretching of the calf muscles. up for at least 2 minutes, the intensity knob
92 Handbook of Practical Electrotherapy

is turned up one step and the machine temperature during the treatment and it
circuit is manually tuned to the patient circuit must be stabilized before being allowed to
by rotating the tuning the tuning knob in be exposed out side temperature, especially
clockwise or anticlock wise direction till in winter.
the needle of the tuning indicator shows
maximum deflection. This function may be Technique of Application of Short-Wave
automatic in a modern machine. Diathermy in Few Specific Disease
• This indicates that two circuits are now in Conditions
tune and maximum transfer of energy is Short-wave diathermy is a versatile modality
taking place between the machine circuit that can be used in many disorders. Its
and the patient circuit. application, as a deep heat modality, to gain
• The intensity knob is now turned up therapeutic benefit in suitable target tissue,
gradually step by step up to 1/3rd to 1/2 mark depends on the ingenuity of the therapist.
from the maximum limit till the should Methods of application for few conditions
feels a comfortable sense of warmth in the part listed in Table 10.1 should serve as a guide
being treated. for the therapist to explore further possi-
• The treatment timer is then set for the bilities.
desired period, i.e. 10 to 30 minutes. The
patient is reminded to use the call bell to MICROWAVE DIATHERMY (MWD)
summon the therapist in case of any over or
under heating or any discomfort. Definition: Microwave diathermy (MWD)
• After the treatment time is over, most can be defined as a deep heat modality that
equipments cut-off the power automati- is similar in concept, but differs widely in its
cally. Turn the intensity knob to zero, bio-physics and application from the short-
remove the electrodes from the body and wave diathermy.
inspect the part closely for any reddening.
Biophysics
• Ask the patient to rest on the plinth for 5
minutes after the treatment is over, before • Microwave diathermy utilizes electromagnetic
being allowed to get up. SWD creates energy with a frequency of 2450 Hz and
pooling of blood in the treated area, lowering wavelength range of 10 to 12 cm.
the blood pressure and depriving the brain of • A composite oscillator known as a magnet-
adequate blood supply. This may lead to ron produces MWD. The magnetron con-
positional vertigo if the patient is allowed sists of ring-like perforated iron core, with
to get up suddenly after the treatment. multiple holes drilled in such a way that,
This precaution is particularly relevant in flow of electrons over theses holes create
pelvic diathermy or cable method where large a electromagnetic frequency, response that
volume of blood is heated. vary in proportion to the velocity and the
• The patient is then allowed to dress and electromotive force moving the electrons.
asked to wait indoor for another 5 to 10 In the frequency of 2450 Hz it is called the
minutes before stepping out. This pre- medical microwave energy.
caution is essential to avoid sudden exposure, • The electromagnetic energy thus produced
since there is significant rise in the body is directed through a co-axial cable to an
 Table 10.1: Technique of application of short wave diathermy in few specific disease conditions

Condition Patient position Method of choice Electrode Duration of Specific Supplementary

placement treatment precaution therapy
Low Back Pain
Sacroiliitis Prone lying on Condenser field, Coplaner 15-30 minutes Avoid exposure 10 minutes of
a padded- using 8”×10” covering the with mild heat, during menstrua- surged faradic
wooden plinth, pads affected area, once a day, on tion or upper GI stimulation
with pelvic and or use felt spacers alternate days bleeding before SWD
Lumbago ankle support Inductance field under pads or or daily for gives better
with rolls of using a cable air-spacing with 10-15 sittings result in relief
towel or hinged drum drum electrodes of pain and
electrodes muscle spasm.
Knee Joint
Osteoarthritis Long sitting or Condenser field, Transarthral contra- 15-20 min once Avoid exposure Effect of SWD
Rheumatoid supine on a using 6”× 8” planer/cross-fire a day, on alternate in acute infla- can be magnified
arthritis padded-wooden pad or 6” method days or 10-15 min mation severe by prior applica-
Trauma plinth with a roll diameter disk Hinged-drum once a day, daily osteoporosis, tion of surged
under the knee electrodes or covering the top suspected faradic stimula-
Inductance field and both sides of fracture tion, at sex
using a cable or the joint or cable surges per
hinged drum coiled around the second, for 10
electrodes joint minutes.
SWD may be
followed up
with pain-killing
gel massage and
IR for 10 minutes
Knee Joint
Chondromale- As above Inductance field Hinged-drum As above As above As above
cia, patella using a cable covering the top
chronic or hinged-drum and both sides
synovitis electrodes of the joint or
cable coiled
around the joint
Contd...
Deep Heat Therapy 93
 94
Contd...

Condition Patient position Method of choice Electrode Duration of Specific Supplementary

placement treatment precaution therapy
Frozen shoulder Sitting on a Inductance field- Hinged-drum 15-20 minutes Watch for bony 10 minutes of
wooden chair using hinged- covering the top once a day prominences surged faradic
with arm rests, drum and both sides of stimulation before
feet resting on a Condenser field, the joint SWD gives
rubber foot mat using 6” × 8” Transarthral place- better result in
Supine lying on pad or 6” ment on the front relief of pain and
a padded-wooden diameter disk and back of the muscle spasm.
plinth electrodes joint
Pelvic inflamma- Sitting on a Condenser field, Pads over the lower 30 minutes OD Avoid exposure Watch for vertigo.
tory disorders wooden arm chair, using 8” × 10” abdomen and under during menstru-
Handbook of Practical Electrotherapy

feet resting on a pads the buttocks. ation or in

rubber foot mat Use felt-spacers presence of IUD.
Supine lying on a under the pads.
padded-wooden
plinth

COPD Prone lying on a Condenser field, Coplaner method, 20 minutes OD Avoid exposure Before SWD
Bronchitis padded-wooden using 8” × 10” covering the in acute respi- exposure, massage
or Asthma plinth, with pads cervicodorsal or ratory distress the chest wall with
pelvis and ankle or dorsolumbar or or menthol and
support Inductance field contraplaner acute lung salicilate ointment
or using hinged- method on the infections and followed
side lying drum electrodes upper chest. Use by IR on the chest
or felt-spacers for better results.
Crook lying with under pads or
a roll under the air-spacing with
knee. drum electrodes

Contd...
Contd...

Condition Patient position Method of choice Electrode Duration of Specific Supplementary

placement treatment precaution therapy
Sinusitis – Sitting on a Condenser field, Contraplaner 10 minutes of Use two layers Kneading massage
Maxillary and wooden arm using one method mild heating of towel to cover to the
frontal sinus chair, feet butterfly pad Coplaner method the forehead, neck helps relieve
inflamation resting on a covering the nose and eyes concurrent
rubber foot mat frontal and the are kept clear muscle spasm
Supine lying on maxillary sinuses of obstruction
a padded-wooden and a large dis-
plinth persive pad under
the neck
Inductance field
using hinged
drum electrodes
covering the
frontal and the
maxillary sinuses
Deep Heat Therapy 95
96 Handbook of Practical Electrotherapy

antenna, mounted inside a hard plastic superficial targets like trigger points,
shell, known as an applicator. The electro- fibromyositis, epicondylitis etc.
magnetic wave released from the appli-
cator is directed to the target tissue. Contraindications for
• There is no need for tuning in MWD, since Microwave Diathermy
the target tissue, unlike in SWD, is not a • MWD is strictly contraindicated in pre-
part of the circuit. sence of pacemakers or deficit in thermal.
• The intensity levels are constant for • Avoid exposure over genitals, eyes or
individual applicators and are printed on gravid uterus.
the directors for reference during treat-
ment. Technique of Application of
• The dosage of MWD is governed by the Microwave Diathermy
inverse square law, which implies that
greater the distance from the source of the Patient Preparation
radiant energy lesser will be its intensity. • Patient is positioned suitably on wooden
Clinically, the patient should experience a plinth or chair to ensure adequate and easy
sensation of comfortable warmth. access to the target area.
• The penetration of MWD, like any electro- • Part to be treated is exposed and rest of
magnetic energy, is directly proportional the body is draped with a sheet.
to its frequency, though clinically for the • Clean the skin of the target area and
therapist; heat production is more a result inspect for cuts, skin lesions or bruises.
of absorption of energy, than of linear
penetration. Hence its absorption of MWD Selection of Treatment Applicator
is far more relevant to study.
• Shape of the treatment applicator may be
• Absorption of microwave energy, like that
small circular, large circular or rectangular,
of the shortwave, depends on the relative
each offering field of radiation in the shape
densities of the tissues and the clinical
of the applicator.
effect depends on the type of tissue
involved. • Selection of treatment applicator therefore
• It is believed that MWD is absorbed better depends on the shape of the target area.
by fat than most other tissues. Since fat is • Since the microwave energy is emitted in
very superficial, the direct thermal effect a divergent field, the extent of its diver-
of MWD is restricted to relatively super- gence and focusing of the field, like the
ficial area. Any effect on deeper tissues is focusing of a light, depends upon distance
mainly due to heat transfer from the between the applicator and the skin.
heated superficial fat layer. • A compact fluorescent tube (CFL) may
used by the therapist to detect the concen-
Indications for Microwave Diathermy trated area of focus as well as the periphery
• Broad clinical indication of MWD is of the field. The lamp will glow the
similar to SWD. brightest in the concentrated field and
• It is preferred in cases where more concen- gradually fade as the CFL is moved to the
trated and localized heating is required in periphery of the field.
 Deep Heat Therapy 97

Selection of Appropriate Power Level and at medium and then adjust the distance of
Application of Treatment the applicator from the skin depending
upon the heatfelt by the patient.
• The equipment should be turned on at • The distribution of the field may be
least five minutes before the treatment to checked using the CFL tube to ensure
allow the magnetron to develop enough adequate distribution and correct focus of
charge to produce adequate emission of the microwave energy.
electromagnetic energy. • The patient feed back should be a sensa-
• As per inverse square law, the distance of tion localized heat, the intensity of which
the target from the applicator determines can be adjusted simply be moving the
the dosage of microwave. applicator closer or away from the skin.
• The distance from the applicator to target Alternatively a lower or higher power
is critical for optimum distribution of the setting, if the equipment offers the option
field, which must be measured with a built of different intensity levels.
in distance regulator on the treatment • The optimum duration of treatment is in
head. the range of 10 to 20 minutes for smaller
• Closer the head to the target lesser the areas like elbow, wrist or ankle and 25 to
power level and vice versa. 30 minute for large areas like the low back,
• It is recommended to set the power level knee or shoulder.
98 Handbook of Practical Electrotherapy

11
Therapeutic Ultrasound
(US Therapy)
Sound can be defined as a periodic mecha-
nical oscillation of an elastic medium such as
air or water. Sound energy can be produced
from an oscillating source and needs a
medium to transmit. Sound travels through
the transmitting medium in the form of waves
created by alternate bands of compression
(pressing together) and rarefaction (pulling
apart) of the molecules of the medium (Fig.
11.1).
The frequency of the sound wave can be
defined the rate at which such bands of
compression and rarefaction occur in the
medium per second and the wavelength as
the distance between two successive band of
compression or rarefaction.
The velocity at which the sound energy
propagates through the medium depends
upon the physical properties of the medium Fig. 11.1: Wave patterns of ultrasound energy
such as density, specific gravity etc. The
velocity of sound is 0 in vacuum, 344 m/sec and the muscle has the lowest acoustic
in air, 1410 m/sec in water and 1540 m/sec in impedance.
muscles. • Human ear can hear sound with frequency
The resistance offered by the medium to of 20 kHz, i.e. 20000 cycles/sec, whereas
the passage of sound is inversely proportional dogs have hearing range of 50 kHz.
to the velocity and is known as acoustic • Any sound having frequency greater than
impedance. Therefore vacuum has the highest 80 to 100 kHz is classified as ultrasound.
 Therapeutic Ultrasound (US Therapy) 99

It has extensive uses in industrial, medical the conducting medium, producing heat
diagnostic and therapeutic purposes. and mechanical deformation of the me-
dium. When applied to body tissue
DEFINITION ultrasound energy is converted to heat
Ultrasound is a form of mechanical vibration. energy and mechanical micro-massage
Therapeutic ultrasound can be defined as, within tissues, to produce definite physio-
high frequency acoustic energy, available in logical reactions, with definable therapeu-
longitudinal waveforms in the frequency tic benefits.
range of 0.8 to 3.5 MHz.
Biophysics of Therapeutic Ultrasound
The frequencies used in ultrasound therapy
are typically between 0.75 and 3.0 MHz (1 • Therapeutic ultrasound is produced by the
MHz = 1 million cycles per second). high frequency cyclic deformation of a
Since sound waves consists of longitudinal piezoelectric crystal of natural quartz or
waves consisting of areas of compression and synthetic composite materials like Barium-
rarefaction, molecules of any material expo- Titanate and Lead Zirconate Titanate, of
sed to a sound wave will oscillate about a specific thickness, bonded to the metal face
fixed point rather than move with the wave plate of a hand held transducer (Figs 11.2
itself. As the energy within the sound wave is and 11.3).
passed to the material, it will cause oscillation • High frequency electric current is applied
of the molecules in that material. Clearly any through a co-axial cable to the piezoelectric
increase in the molecular vibration in the
tissue will result in heat generation, and
ultrasound (US) can be used to produce
thermal changes in the tissues, though current
usage in therapy does not focus on this
phenomenon.
In addition to thermal changes, the
vibration of the tissues appears to have effects
which are generally considered to be non-
thermal in nature, though, as with other
modalities (e.g. pulsed short wave) there must
be a thermal component however small. As
the US wave passes through a material (the
Fig. 11.2: Ultrasonic transducers of different types –
tissues), the energy levels within the wave will
(top) with fixed head, (bottom) with swivel head.
diminish as energy is transferred to the Modern machines have transducers with contact
material. The energy absorption and attenua- indicator. Optimum contact with the skin is essential
tion characteristics of US waves have been for adequate transfer of ultrasonic energy to the body
documented for several types of tissue. tissue. Whenever the contact is inadequate, the
contact indicator lamp glows red and the flow of
• The ultrasound energy is non-electromag- ultrasonic energy stops. The treatment timer also
netic in nature and it creates successive stops automatically and is not resumed till the contact
bands of compression and rarefaction in has been re-established
100 Handbook of Practical Electrotherapy

beam of ultrasound waves, with little or

no dispersion of energy.
• The ultrasound energy produces mecha-
nical pressure waves in the tissue fluid
medium through which it passes, with
resultant release of heat, micromassage
and acceleration of protein synthesis.
• The ultrasound energy has a maximum
penetration of 3 to 5 cm in the living tissue;
however the depth of penetration varies
inversely to the frequency.
• Commonly used frequencies of therapeu-
tic ultrasound are 3 MHz and 1 MHz.
Fig. 11.3: Different sizes of ultrasonic transducer • At 3 MHz, the depth of penetration is
head–(top) 3 sq cm size head is used for very loca- relatively shallow, with maximum absorp-
lized treatment area (9 sq cm), usually used with 1 tion of energy and therefore greater effect,
MHz frequency, (bottom) 5 sq cm size head is
indicated for larger areas (max 15 sq cm), commonly
in the superficial tissues like the capsule
used with 3 MHz frequency of the ankle, knee or shoulder joint.
• At 1 MHz, the depth of penetration is
crystal to produce mechanical deformation deeper, with maximum absorption of
of the crystal through reverse piezoelectric energy and therefore greater effect, in the
effect. The rate of deformation or reso- deep tissues like muscles of the back or
nance of the crystal depends on the fre- gluteus region.
quency of the applied oscillating current. • Therapeutic ultrasound may be applied in
• This cyclic resonance of the piezoelectric continuous or pulsed mode. In continuous
crystal to the applied current frequency mode the thermal effect is more pronoun-
sets up a vibration in the metal face plate ced and in pulsed mode the non-thermal
of the transducer, to which the crystal is effects are more prominent.
bonded. • Mark-space ratio—The ratio between the
• Air, with acoustic impedance of 1, reflects flow time and off time of ultrasound
ultrasound waves. Hence a conducting energy in pulsed mode application.
medium like ultrasound gel, degassed Commonly the “on time” is 2 msec and the
water, glycerine or liquid paraffin, in the “off time” varies from 2 to 8 msec.
above order of preference, may be used to
eliminate air-space between the metal face Points to Ponder
plate of the transducer and the body sur- • The beam of ultrasound energy is cylindri-
face. These mediums are called coupling cal in shape, at least in the near field. The
mediums, which apart from transmission of diameter is nearly the same as the dia-
U.S., also reduces friction between the meter of the transducer.
transducer head and the body surface. • The concentration of the energy is very
• These vibrations, when transmitted irregular in the near field, which becomes
through a conducting medium, produce a more uniform in the far field.
 Therapeutic Ultrasound (US Therapy) 101

• The near zone of the ultrasound (Fresnel 4. The ultrasound beam refracts when travel-
zone) is therapeutically relevant and it ling from one tissue to another, due to
varies in direct proportion to the square difference in acoustic impedances of
of the radius of the transducer head and tissues.
inversely to the wavelength. 5. Reflection of a part of the ultrasound energy
(30%) takes place at tissue interfaces, resul-
Physiological Effects of Therapeutic
ting in release of heat. Tissue interfaces are
Ultrasound and its Applications
adjoining surfaces between two types of
The Thermal Effect issues, e.g. the bone/peritoneum, fascia/
muscle, muscle/periosteum, bone/liga-
Therapeutic ultrasound, when applied in ment or bone/capsule, which become the
continuous mode, at an intensity of 0.5-3 sites of heat concentration.
W/cm2, through following mechanisms, pro-
6. Maximum reflection of ultrasound takes
duces heat, due to:
place between the bone/periosteum
1. Absorption of the sound energy in body
interface, causing intense heating, which
tissues, resulting in increased tissue tempe-
may be felt as a sudden sharp ache at the
rature. If the tissue temperature can be
site of application. This is commonly felt
raised to 40-45°C for at least 5 minutes, it
over areas with minimum soft tissue cover,
produces therapeutic benefits such as
like the epicondyles of the elbow, joint line
increased pain threshold, increased
of the knee and ankle, acromial arch etc.
collagen extensibility, increased enzyme
This can heat the tissues to dangerous
activity, increased tissue perfusion and
levels, particularly if the tissue has poor
decreased nerve conduction velocity.
2. The extent of energy absorption depends on blood supply, e.g. tendons. The intensity
the protein content, blood supply and the of ultrasound must be reduced imme-
depth of the tissue, as well as the frequency diately if such pain occurs and bony
of the ultrasound used. Tissues with high prominences must be avoided all together.
protein content like muscles, ligaments, 7. Hot spots may also be created under the
tendons and blood, tend to absorb more transducers, if inadequate coupling me-
energy as compared to fat. This deferential dium is used, resulting in uneven distri-
heating of tissues with highly localized bution of the sound energy or if the head
effect is the unique advantage of ultra- is kept stationary, creating standing waves.
sound therapy.
The Non-thermal Effect
3. Depth of heating or penetration, produced by
ultrasound, depends on the half value Ultrasound energy can produce significant
distance for a given frequency. The half effect in the tissues, without its heat compo-
value distance is the depth of tissue at nent being used, as in pulsed mode appli-
which the intensity of the ultrasound cation. Such reactions are due to non-thermal
energy reduces by half. Ultrasound the- effect of ultrasound, which can be described
rapy given at 3 MHz has an average half as follows:
value distance of 3 to 5 mm and at 1 MHz 1. Mechanical effects: The high frequency
it is 11 mm. vibrations created by ultrasound energy
102 Handbook of Practical Electrotherapy

produce deformation of the molecular to set up a standing wave. The standing

structures of loosely-bonded substances waves have points of maximum and
like the soft tissues. This produces micro- minimum pressure, known as antinodes
massage of soft tissues which has sclero- and nodes, at the distance of half a
lytic effect, i.e. it can break down calcifica- wavelength. The tissue exposed to the
tion or adhesions in soft tissue, resulting nodes are benefited by microstreaming
in relief of muscle spasm, softening of scars and stable cavitations effects but those
tissues, release of contractures and
exposed to the antinodes may be seriously
adhesions.
damaged due to excessive microstreaming
2. Cavitations: Kinetic energy of the ultra-
and unstable cavitations. To achieve safe
sound beam is absorbed by tissue fluid,
insonation, the therapist must avoid
releasing gas bubbles, due to molecular
agitation. These bubbles resonate with the creating standing waves by moving the
ultrasound frequency within and outside transducer continuously while giving
the cell membrane, creating faster trans- ultrasound and use minimum intensity
migration of ions at cellular level, having required.
beneficial effects on the cell. This is known
as stable cavitations. However, if the gas Points to Ponder
bubbles pick up too much energy from the • Attenuation of ultrasound takes place due
ultrasound beam, they tend to expand and to absorption, reflection and refraction of
form unstable cavitations, accumulating a ultrasonic energy.
lot of heat. After limited degree of expan-
• Absorption depends on protein and water
sion, the gas bubbles may burst releasing
content of individual tissue, as well as, the
a lot of heat deep within the tissues
wavelength and frequency of the ultra-
causing serious damage.
sound.
3. Acoustic streaming: Intracellular fluid
moves in the direction of the ultrasound • Reflection and refraction takes place at the
beam, like rain drops blowing in the tissue interface and depends on the
direction of strong wind. Fluid tends to be relative density of the tissues forming the
stream towards the cell membrane, creat- interface.
ing high-pressure areas along the cell • Continuous ultrasound produces mainly
membrane altering the permeability of the thermal effect on tissues.
cell membrane temporarily during ultra- • Pulsed ultrasound produces non-thermal
sound exposure. Free radicals and other effects such as cavitations, acoustic stream-
waste products of cell metabolism are ing, standing waves and micro massage.
expelled and protein synthesis and repair
process of the cell is activated. Indications for Ultrasound Therapy
4. Formation of standing waves: A percentage
of the ultrasound energy is reflected when Ultrasound therapy may be used for
the beam crosses from one tissue to following conditions:
another at the interface. The reflected • Acute soft tissue injuries—It has now
energy resonates with the incedent energy become a standard practice in sports
 Therapeutic Ultrasound (US Therapy) 103

physiotherapy to use of ultrasound the- to begin. Protein synthesis effect of ultra-

rapy in acute soft tissue injuries, even in sound also helps in growth of granulation
the sports filed. The reasons are as follows: tissue, provided the wound is free of
1. Mechanical effect of ultrasound helps to infection. It further promotes the plasticity
remove post-traumatic exudates and of the newly formed granulation, to mould
reduce the risk of adhesion formation. it in such a way, that the healed tissue
2. Mild thermal effect of ultrasound helps to regains near normal texture.
induce relief of pain and allows early
movement of the injured part. Points to Ponder
3. Protein synthesis accelerated by bio- • The main therapeutic application of
logical effect of ultrasound helps in ultrasound are healing of chronic ulcers,
rapid healing of the damaged tissue. acute soft tissue lesions, pain relief and
• Inflammation of joint capsules, tendons, softening of scars and contracture.
ligaments, bursa associated with acute • Therapeutic ultrasound may be used for
exacerbation of chronic degenerative like diagnosis of stress fractures by the sharp
osteoarthritis or inflammatory disorders pain it will produce immediately from the
like rheumatoid arthritis, gout, R.S.I. site of the fracture. This may prove useful
(repetitive stress injuries). Mechanical when radiological findings are incon-
effect of ultrasound helps to remove post- clusive.
inflammatory exudates, thermal effect of Contraindications for
ultrasound helps to induce relief of pain, Ultrasound Therapy
sclerolytic action of ultrasound helps to
Ultrasound therapy must not be used in
break down unwanted calcification of soft
following conditions:
tissue, helping to restore function.
• Vascular conditions (Thrombophlebitis or
• Scar tissue: Sclerolytic action of ultrasound
Phlebothrombosis): A clot may break off
helps to soften scar tissue, which makes
within the blood vessel due to the mecha-
the contracted scar more pliable and easy
nical effect of ultrasound to create an
to stretch. Mechanical effect of ultrasound embolus.
helps to create micro massage of adherent • Poor blood supply: (Burger’s disease/
scar and free it from the underlying tissue. arteries/atherosclerosis/varicose veins):
• Chronic indurate oedema: Mechanical effect of Burn injury in the deep tissue may arise
ultrasound creates micro massage in tissue due to poor dissipation of heat, generated
with chronic oedema, helping to break- by ultrasound energy in tissues with
down adhesions between tissue layers and deficiency of blood supply. Use pulsed
allows free circulation of blood and lymph mode U.S. to avoid heating the tissue but
that accelerates the drainage of chronic still get its beneficial effect.
oedema. • Infected lesion: (Carbuncles/cellulites/
• Wound healing: Micro-streaming effect of abscess): Infected particles may break
ultrasound promotes ionic exchange at the loose due to the mechanical effect of ultra-
cellular level, creating a favourable sound and enter the blood stream to
environment for healing of injured tissues spread to other areas or create septicaemia.
104 Handbook of Practical Electrotherapy

• Suspected neoplasia: (Benign/malignant): connected to the mains by the mains cable

Cancerous cells may break loose and (Fig. 11.4). The transducer jack is fitted and
spread to other areas creating metastasis secured tightly to the output socket.
due to the mechanical effect of ultrasound. Keeping all the controls at zero position,
The biological effect of US therapy may the apparatus is turned on through the
initiate growth or change benign tumours power switch. Timer is set for two minutes,
to in to malignancy. few drops of water is placed on the
• Tissues exposed to radiation: (Deep X-ray transducer head holding it horizontal
therapy/cobalt therapy) Tissues devita- facing up wards and the power is gra-
lised by radiation may breakdown when dually increased by turning the intensity
exposed to the combined effect of heat, knob clockwise, till ripple is observed in
mechanical and biological effect of ultra- the water drops. This is known as the
sound therapy. fountain test, which indicates that the
• Pregnant uterus: Mechanical effect of machine is giving satisfactory output of
therapeutic ultrasound may damage the ultrasound energy (Fig. 11.5, Plate 8). The
foetus. The ultrasound scanning utilizes intensity is then reduced to zero by turning
different frequency, which is harmless to the intensity knob in anticlockwise
the foetus. direction. The duration of fountain testing
• Heart diseases: Patients with demand type must be limited to few seconds only;
pacemaker should not be exposed to
therapeutic ultrasound because the high
frequency electrical field associated with
ultrasound may interfere with the function
of the pacemaker. In those cases without a
pacemaker, ultrasound exposure to cervi-
cal region must not be given as it may
cause stimulation of vagus nerve, leading
to arrhythmia of the heart.

Points to Ponder
Ultrasound is strictly contraindicated in the
presence of:
• Neoplasia and malignancy
• Pregnant uterus, ovary and testes Fig. 11.4: Digital ultrasonic machine—on the extreme
• Haemorrhage or ischemia left is the digital treatment timer indicating treatment
• Acute infection time in minutes. Below are the timer control switches
• The eyes, ear and exposed nerve. for setting and resetting the treatment time. To its right
is the selector switch for continuous and pulsed mode
of ultrasonic application. Next to it is the rotary switch
Technique of Application of
for intensity control. At extreme right is the digital
Ultrasound Therapy display for intensity in W/cm2. Below it is the output
socket to which the jack of a coaxial cable is
a. Setting up and testing of the ultrasound
connected. The other end of the coaxial cable is
therapy equipment is the first step in connected to the transducer seen on the top of the
application of treatment. The apparatus is machine
 Therapeutic Ultrasound (US Therapy) 105

otherwise the quartz crystal may be nences, with adequate soft tissue cover, like
damaged due to reflection of ultrasound the back, chest wall, fleshy portions of the
from air. After testing, the power may be extremities and around various large and
turned off or the timer may be reset for the medium-sized joints (Fig. 11.7, Plate 8).
duration of treatment, if a patient is • Adequate quantity of coupling medium is
available and ready for treatment. squeezed on to the faceplate of the trans-
b. Preparation of the patient: The patient is ducer and on the skin surface over the tar-
positioned in a comfortable position, either get area.
sitting on a wooden chair or lying down • The coupling medium is a fluid or gel that
on a plinth, depending upon the part to
is used to eliminate air-space between the
be treated. The part to be treated is
transducer and the skin to ensure effective
exposed, well-supported, with the rest of
transmission of ultrasound energy. Coupl-
the body carefully draped with a sheet for
ing mediums may be liquid paraffin,
sake of modesty of the patient. While
treating tightened soft tissue or shortened glycerine, aqua-based gel or degassed
tendons, ligaments or muscles, the tissue water. Different mediums have different
must be partially-stretched when being rate of transmission of ultrasound energy.
treated. The treatment must be carried out Liquid paraffin has the lowest rate of
in a screened off area with good light and transmission at 19%, degassed water at
no cross draught of breeze. 59%, glycerine at 67%, while the aqua-
c. Technique of application of therapeutic based sonic gel has the highest rate of
ultrasound varies depending on the site, transmission at 72.6%
depth of target tissue, underlying patho- • The transducer is then placed on the skin
logy and the desired clinical effect. surface over the target site, holding the
The commonest method of application is with face plate parallel to the skin surface
direct contact of the transducer on the skin sur- firmly.
face over the target tissue (Fig. 11.6, Plate 8). • The transducer is then moved gently over
Indirect application of ultrasound is done the skin to apply a thin film of coupling
by the water bath and the water bag method, medium over the skin on the target area.
which are used for specifically for irregular • The timer is then set for the duration of
areas with bony prominences and thin soft the treatment and the intensity is gra-
tissue cover. dually increased to the desired level, while
Specialized applications of ultrasound are moving the transducer slowly in concentric
phonophoresis and combined ultrasound and circles over the skin.
iontophoresis, which are used for adminis- • The speed of movement of the transducer
tration of therapeutically useful substances should not exceed 2 to 3 cm/sec, to ensure
transcontinuously to the target tissue. adequate insonation of the target tissue.
• Treatment intensity generally used is 0.3
Direct Contact Method to 3.0 W/cm sq depending on the treat-
ment goal.
This is the commonest method of ultrasonic • For acute conditions or arrears with thin
application, suitable for relatively flat sur- soft tissue cover, like the hand or wrist,
faces, free of irregularities and bony promi- lower intensities in the range of 0.3 to 0.8
106 Handbook of Practical Electrotherapy

W/cm sq is used. Alternatively pulsed dose of sound energy, which may cause
mode of ultrasound may be preferred if irreversible damage to the tissues
heating effect is not desired. (Figs 11.8 to 11.15).
• For chronic conditions or areas with thick • Presence of DVT, acute sepsis or inflam-
tissue cover, like the back, higher inten- mation, healing fracture or osteoporosis,
sities in the range of 1 to 3 W/cm sq in metal or plastic implant in the treatment
continuous mode may be used. field is strict contraindication to ultra-
• Duration of treatment may be set for 3 to sound therapy.
10 minutes, depending on the area being • Care should be taken against overdose
covered. For effective treatment the area while treating primary repair of tendons,
covered should never exceed three times ligaments and over-grafted skin.
the surface area of the transducer head, i.e.
5 sq cm × 3 = 15 sq cm, for every five Water Bag Method
minutes of application. Large areas may This is the method of choice for indirect
be divided in to grids of 15 sq cm each with application of ultrasound over irregular bony
a marker pen and then treated. area like the dorsum of the hands, feet, ankle
• Specific indications for this method of joint, epicondyles and olecranon of the elbow.
application are bursitis, tendonitis, liga- It is also an alternative method of indirect
ment strain or sprain, musculofascial application to proximal portions of the body
trigger point (fibromyositis nodules), scars which cannot be treated by full immersion in
and keloids, neuromas at the end of stump
a water bath, e.g. the temporomandibular
of amputed limb and margin of open
wounds.

Precautions to be Observed in
Direct Contact Method
The patient must be instructed carefully about
the sensation being felt during ultrasonic
therapy.
• With continuous mode of ultrasonic
energy, the patient should feel mild
warmth, whereas with pulsed ultrasound
there should never be any feeling of
warmth.
Fig. 11.8: Application of ultrasonic therapy over the
• If the transducer is kept stationary mo- medial epicondyle of the elbow for the treatment of
mentarily, particularly over a bony pro- medial epicondylitis (golfers elbow). Ultrasonic therapy
minences, the patient may feel intense heat is the modality of choice for golfers elbow. Since the
sensation at a point. This is due to peri- area is bony the ultrasonic should be in pulsed mode.
osteal pain caused by concentration of Care should be taken not to keep the transducer
stationary, because that may create standing waves,
ultrasound energy reflected by the bone in
which may produce periosteal irritation and pain. For
the periosteum. The therapist must be best results, ultrasonic application must be followed
alerted immediately if any such feeling up with deep friction massage and stretching of the
occurs, as this indicates dangerous over- common attachment of the flexor tendons
 Therapeutic Ultrasound (US Therapy) 107

Fig. 11.9: Application of ultrasound to the palmar Fig. 11.11: Application of ultrasound to the temporo-
fascia for treatment of Dupuytren’s contracture. mandibular joint. Since the area is bony the ultrasonic
Ultrasonic therapy in pulsed or continuous mode may therapy should be in pulsed mode. Care should be
be opted for depending up on whether the condition taken not to keep the transducer stationary, because
is acute or chronic respectively. For best results, that may create standing waves, which may produce
ultrasonic application must be followed up with deep periosteal irritation and pain
friction massage and stretching of the soft tissue
contracture

Fig. 11.12: Application of ultrasound to the sterno-

costal joint for the treatment of costochondritis. Since
Fig. 11.10: Application of ultrasound to the supra- the area is bony the ultrasonic therapy should be in
spinatus tendon and subacromial bursa for treatment pulsed mode. Care should be taken not to keep the
of rotator cuff impingement syndrome. Ultrasonic transducer stationary, because that may create
therapy in pulsed or continuous mode may be opted standing waves, which may produce periosteal
for depending up on whether the condition is acute irritation and pain. For best results, ultrasonic
or chronic respectively. For best results, ultrasonic application must be followed up with deep friction
application must be followed up with deep friction massage and stretching of the contracted pectoral
massage and stretching of the contracted soft tissue aponeurosis
108 Handbook of Practical Electrotherapy

Fig. 11.13: Application of ultrasonic therapy over the

lateral epicondyle of the elbow for the treatment of
lateral epicondylitis (Tennis elbow). Ultrasonic therapy
is the modality of choice for tennis elbow. Since the Fig. 11.15: Application of ultrasonic therapy over the
area is bony the ultrasonic therapy should be in pulsed carpal tunnel on the ventral aspect of the wrist for the
mode. Care should be taken not to keep the treatment of carpal tunnel syndrome. Ultrasonic
transducer stationary, because that may create therapy is the modality of choice for carpal tunnel
standing waves, which may produce periosteal syndrome. Since the area is bony the ultrasonic
irritation and pain. For best results, ultrasonic therapy should be in pulsed mode. Care should be
application must be followed up with deep friction taken not to keep the transducer stationary, because
massage and stretching of the common attachment that may create standing waves, which may produce
of extensor tendons periosteal irritation and pain

joint, acromioclavicular arch, sternocostal

junctions, etc.
• A latex rubber surgical glove is filled with
degassed water.
• Water is degassed by boiling it for few
minutes which removes all the dissolved
gas bubbles, which otherwise may reflect
ultrasound energy during treatment.
• The opening of the gloves closed with a
rubber band.
• A thin film of coupling gel is applied over
Fig. 11.14: Application of ultrasonic therapy over the the part to be treated, as well as, on either
tendon of abductor policis longus, extensor policis surfaces of the palm portion of the gloves
brevis and extensor policis longus on the lateral filled with degassed water. The film of
aspect of the wrist for the treatment of tenosynovitis
(de Quervain’s disease). Ultrasonic therapy is the
coupling medium eliminates air-space
modality of choice for de Quervain’s disease. Since between the transducer head and the
the area is bony the ultrasonic therapy should be in surfaces through which the ultrasound has
pulsed mode. Care should be taken not to keep the
to pass to reach the body tissue.
transducer stationary, because that may create
standing waves, which may produce periosteal • The bag is then placed over the target area
irritation and pain and may be fixed in place on the skin with
 Therapeutic Ultrasound (US Therapy) 109

sticky paper tape at its edges. The water Water Bath Method
bag evens out the bony irregularities, thus This method is most suitable for indirect
avoiding concentration of ultrasound application of ultrasound over bony areas
energy over bony prominences. with irregular surface or with sensitive or
• Ultrasound is applied by directly on the delicate skin, e.g. skin grafts or newly-healed
outer surface of the water bag. The ultra- wound, where direct contact or water bag
sound energy passes through two layers method may be unsuitable due to the friction
of latex and the degassed water to reach involved.
the target tissue. • A plastic wash tub is filled with degassed
• Since a significant amount of energy is water. Plastic is used because it reflects
absorbed by the layers of latex and water minimum amount of ultrasound energy.
the intensity of ultrasound used as well as • The part to be treated is immersed comple-
the duration of the treatment must be 30 tely in the degassed water.
• The transducer head is placed under the
to 50 percent more than that used in case
water and held 1 mm away from and
of direct contact method over similar areas.
parallel to the skin surface.
• As the intensity is increased the head is
Precautions to be Observed in
moved in small concentric circles at a
Water Bag Method
speed of 3 cm/sec, covering the entire
• Position of the bag must be accurate in surface of the target area as the intensity
relation to the target tissue and the is increased to the desired level.
ultrasound head keeping the head as • Periodically air bubbles must be wiped off
perpendicular to the skin surface as the body part and the transducer.
possible.
• Ultrasound beam refracts while travelling Precautions to be Observed in
from one medium to the next. In water bag Water Bath Method
method the ultrasound beam has to travel It will be wise to remember that in this method
through first layer of latex, then the layer a high frequency electrical device is being
of degassed water and then the second used in an environment full of water. Hence
layer of latex before it reaches the skin. So to avoid the electric shock to the patient and
many layers in the path of the ultrasound the therapist following points must be
beam cause significant divergence. Allow- checked.
• The power supply must have proper earth
ance should be made for this divergence
connection and the equipment must not
of the ultrasound beam by selecting a
have any leakage of current to the body of
target area not larger than the size of the the machine. The fuses must be properly
transducer, i.e. 5 cm sq and the bag has a calibrated and installed. The transducer
tendency to slip over the skin making it should be completely waterproof. The
difficult to focus the beam perpendicular floor of the treatment area should have a
to the skin. Hence the bag must be held in rubber or coir floor mat to stand or rest
position with sticky tape. the feet.
110 Handbook of Practical Electrotherapy

• Prolonged soaking in water can devitalise

and damage delicate or grafted skin. This
point must be kept in mind while using
the water bath method. Hence the dura-
tion of the immersion of the part should
be limited to only for the period of the
treatment. After the treatment a thin layer
of petroleum jelly or lanolin based skin
cream may be applied on the part.

Phonophoresis
It is the use of ultrasound energy to introduce
molecules of medication through the skin into Fig. 11.16: Application of ultrasound to the clavicular
the subcutaneous capillary network, from fossa for treatment of brachial neuralgia. Ultrasonic
where these molecules can be carried by the therapy in pulsed or continuous mode may be opted
blood stream to deeper tissues. The molecules for depending upon whether the condition is acute or
chronic respectively. For best results, ultrasonic
thus introduced dissociate into elements and
application must be followed up with adverse neural
radicals within the tissue, which then combine tension stretching of the brachial roots
with the free-radicals existing in the blood
stream, to produce the desired clinical effect.
The available clinical evidence suggests that
the depth of penetration of such molecules is
in the range of 1 to 2 mm.
Technique of Application
• A small quantity of the medication in gel
or cream or ointment form is rubbed in to
the skin over the target area. Gel form
responds well to the passage of ultra-
sound, whereas cream and ointment may
inhibit the process of insonation. It is
therefore important to use gel form
wherever possible. Wherever cream or
ointment-based medications are the only Fig. 11.17: Application of ultrasonic therapy over the
option, be sure to massage the medication medial collateral ligament of the knee for the treatment
thoroughly into the skin before applying of strain, sprain or osteoarthritis of the knee. Ultrasonic
ultrasound (Fig. 11.16). therapy is the modality of choice for medial joint-line
• Same gel or ointment mixed with standard tenderness of the knee. Since the area is bony the
ultrasound gel is placed over the trans- ultrasonic therapy should be in pulsed mode. Care
should be taken not to keep the transducer stationary,
ducer head as coupling medium.
because that may create standing waves, which may
• Ultrasound is then applied to the target produce periosteal irritation and pain. For best results,
area by the direct contact method ultrasonic application must be followed up with deep
(Fig. 11.17). friction massage over the ligament
 Therapeutic Ultrasound (US Therapy) 111

• Standard treatment intensity used for

phonophoresis may be 1 to 2 w/cm sq.
• Standard treatment duration may be
5 to 10 min.
• Treatment done with low intensities over
long periods is more effective in intro-
ducing the medication through the skin
(Fig. 11.18).
• Selection of the medication depends on the
pathophysiology of the disorder being
treated and the desired effect.
Fig. 11.18: Application of ultrasonic therapy over the
Phonophoretic Agents: Indications, Possible lateral collateral ligament of the ankle for the treatment
Adverse Reactions and Contraindications of strain or sprain. Ultrasonic therapy is the modality
• Hydrocortisone gel or ointment 1-10%—It of choice for ligament strains of the ankle. Since the
may be used for strong anti-inflammatory area is bony the ultrasonic therapy should be in pulsed
mode. Care should be taken not to keep the
action in acute inflammation of soft tissue. transducer stationary, because that may create
In rare cases skin rashes may be seen standing waves, which may produce periosteal
which is best treated by antihistaminic irritation and pain. For best results, ultrasonic
application must be followed up with deep friction
(cetrizine) drugss (Figs 11.19 and 11.20).
massage over the ligament
• Lidocaine 4-5% gel (xylocaine)—It is very
effective for analgesia and relief of acute
pain with no adverse reactions (Fig. 11.21).
• Methyl salicylate 4.8% ointment (Iodex) or
salicylate 10% ointment (Myoflex)—As a
basic anti-inflammatory agent salicylate
may be considered for chronic painful
disorders of the musculoskeletal system.
Patients sensitive to aspirin should not be
treated with salicylate (Fig. 11.22).
• Iodine 4.7% ointment (Iodex)—It is useful as
a vasodilating, anti-inflammatory and
sclrolytic agent in softening of scar tissue,
soft tissue adhesions, calcification of Fig. 11.19: Application of ultrasound to fibromyositic
nodule in rhomboids muscle. Since the area is fleshy,
ligaments and tendons and adhesive continuous mode of ultrasonic therapy may be used.
capsulitis of joints. Patients that are allergic For best results, Ultrasonic application must be
to sea food should not be treated with followed up with deep friction massage
iodine. In case of skin irritation and itching
give antihistaminic drugs (Fig. 11.23). as a medium for phonophoresis to the
• Zinc oxide creams 20% (Siloderm)—Zinc is edges of the indolent wounds to promote
a healing agent and can be useful in healing. Patients who cannot wear metal
treatment of open wounds. It can be used wrist watch bands or jewellery due to
112 Handbook of Practical Electrotherapy

Fig. 11.20: Application of hydrocortisone phono- Fig. 11.21: Application of Lidocaine phonophoresis
phoresis therapy over the retro-calcaneal bursa of the therapy over the lumbo-sacral junction for the
ankle for the treatment of bursitis with effusion and treatment of acute low back pain. For best results,
acute pain. For best results, ultrasonic application Ultrasonic application must be preceded by infrared
must be followed up with ice massage over the bursa radiation to the painful spot for 10-15 min

Fig. 11.22: Application of Iodex phonophoresis Fig. 11.23: Application of ultrasound to the calcaneal
therapy over the popliteal bursa of the ankle for the spur. Since the area is fleshy, continuous mode of
treatment of chronic bursitis with indurate effusion and ultrasonic therapy may be used. For best results,
dull pain. For best results, Ultrasonic application must Ultrasonic application must be followed up with deep
be preceded with deep heat like SWD over the bursa friction massage

allergic skin reaction are sensitive to metals ledge gained by many practioners in their
and they should not be treated with zinc. clinical practice and should act as a guide to
Consult a skin specialist if adverse reaction the future generations of physiotherapists.
does take place. Pharmaceutical companies almost on daily
The agents of phonophoresis discussed basis are making new drugs, in gel or
above are the fruit of the cumulative know- ointment form, available. It is recommended
 Therapeutic Ultrasound (US Therapy) 113

that the therapists should experiment with the increased accuracy and effectiveness in
application of theses drugs through phono- treating deeper lesions, especially while
phoresis in suitable disease conditions and treating trigger points.
contributes to the data-base of clinical know-
ledge. Biophysics of Combination Therapy
Ultrasound exposure to a peripheral nerve
Combination Therapy Using Ultrasound reduces its resting membrane potential by
and Electrical Stimulation increasing its permeability to various ions,
especially sodium (Na+) and calcium (Ca++).
In general terms, combination therapy
Due to this altered permeability, the nerve
involves the simultaneous treatment with
ultrasound and electrical stimulation. In membrane is taken closer to its response
Europe, the trend is towards using diadyna- threshold, though it does not usually make
mic currents with ultrasound, but in the UK, the nerve fire. The simultaneous application
it is most often combined with two-pole of MF2 pole current through the nerve
medium frequency current. induces the depolarisation, with a much less
current intensity than usual, due to the
Important Considerations sensitization created by ultrasound exposure.
This can easily be demonstrated. If both
• There is a significant lack of published the US and MF are being applied and during
material in this area. And much of the the treatment if the intensity of the US is
information herein is anecdotal or based turned down to zero, the sensation produced
on the experience of those who use the
by the MF will diminish even though the MF
modality frequently.
intensity has not been changed. The intensity
• Broadly, the effects of the combined treat-
of sensation produced by the MF intensify as
ment are those of the individual modali-
the intensity of the US is turned up (Fig. 11.24).
ties. There is no evidence at present for any
additional effects, which can only be
achieved when the modalities are used in
this particular way.
• By combining US with MF 2 pole current,
the effects of each treatment modality can
be realised, but lower intensities of both
are used to achieve this effect.
• The accommodation effects on sensory
nerves that accompany MF treatment are
reduced (or even eliminated)
The therapeutic advantages of combination
therapy are said to be in localising lesions
(especially chronic) i.e. for diagnostic purpose.
Ensuring accurate localisation of the lesion for
application of ultrasound therapy provides Fig. 11.24: Biophysics of combination therapy
114 Handbook of Practical Electrotherapy

In summary, it would appear that by • The ultrasound is turned on, the

combining the two treatment modalities, none duration is set and the treatment head
of the individual effects of the treatments are placed along with a liberal coat of
lost, but the benefit is that lower treatment conducting coupling media on the skin.
intensities can be used to achieve the same Intensity is then increased to the
results, and there are additional benefits in desired level.
terms of diagnosis and treatment times. • The MF is then turned on and the
intensity increased to minimum per-
Technique of Application of ceptible level.
Combination Therapy • Starting with ultrasound the head
Combination therapy is a relatively new form distant from the lesion, gradually
of treatment. The guidelines for application, increase the MF output intensity until
as presented below, are derived from expe- the patient encounters the ‘normal’
riences and findings of different workers in tingling.
the field. Lot of work is still in progress for • Move the ultrasound transducer to-
fine-tuning the procedure and the parameters wards the site of the lesion, noting any
given here are by no means absolute. areas of increased sensitivity, local or
• It is suggested that a continuous US output referred pain.
of 0.5W/cm 2 should be used for this • The point of maximal sensitivity to MF
procedure. stimulation is assumed to be the focal
• A frequency of 1MHz is preferable if point of the lesion, though it will not
available as it gives more effective pene- provide information as to the precise
tration into the tissues. tissue in question, nor to depth
• The MF output is most commonly set to (Fig. 11.25)
100 Hz using a bipolar output. • This test provides only a ‘geographical’
a. As a diagnostic tool location of the trigger point. This posi-
• Place one of the MF pad electrodes in a
position on the body surface so that the
current can pass through the tissue in
question. As the passive electrode it can
be placed on the same aspect of the
limb for superficial lesions or on the
opposite side of the limb for deeper
lesions.
• The other terminal of the MF is connec-
ted any metal part of the ultrasound
transducer with the help of an alligator
clip, turning the transducer into an
active electrode. May modern units
offer special sockets built into the
ultrasound machine to connect one
output terminal of the MF two pole Fig. 11.25: Localisation of trigger point using
current for combined therapy. combination therapy
 Therapeutic Ultrasound (US Therapy) 115

tion is usually consistent and repro- tional effect). When they are dissimilar,
ducible. it may be more effective to apply as two
• Once the focal point of a lesion has been separate treatments.
detected further treatment may be • It is important to observe the usual
done with only ultrasound therapy or precautions applicable for both moda-
combined therapy. lities during combination therapy, i.e.
b. As a treatment protocol: always using a moving treatment head,
• Diagnostic and therapeutic uses of maintain effective contact, the per-
Combination Therapy need not be used pendicular relationship between the
together. treatment head and the patient’s skin
• As a treatment, combination therapy is whenever possible.
appropriate when the therapeutic c. Clinical example:
effects of US and those of MF current • For a patient with an acute lesion of the
are both justified. lateral ligament of the ankle joint,
• The individual doses for the US and IF pulsed ultrasound is justified because
should be those which are appropriate it will promote the repair process and
for the lesion and the therapeutic effects interferential may be used for its effect
desired. There is no evidence that in reducing acute pain.
‘special’ treatment doses are required. • Recommended US dose (based on
However, the intensity of the MF normal dose calculations) should be
current required to produce desired 3 MHz, 0.2 W/cm 2 , Pulse 1:4, 10
effect is likely to be lower than usual. minutes.
• Manufacturers claim that it is not • Recommended interferential dose (for
necessary to incorporate a sweep acute pain) should be 90 to 130Hz,
frequency in the MF current as the bipolar, 10 minutes.
effect of accommodation is minimised. • Interferential pad as the passive elec-
However appropriate MF frequency trode should be placed on the medial
sweep can be used if it is appropriate aspect of the ankle joint.
to the produce the desired effect in the • US treatment head should be applied
target tissues. over the injured component(s) of the
• If the treatment times are dissimilar, lateral ligament.
there is a potential problem in that the • The effect of such combined treatment
US component will usually finish first, could be more effective, than either one
leaving the IF element to continue in modality in isolation, though there is
isolation. The therapist should there- no evidence to prove that by using
fore try to match the treatment time for them simultaneously, there is any
both modalities by selecting an opti- advantage over using them sequen-
mum duration of treatment wherever tially one after the other.
possible. d. Contraindications for combination therapy:
• If treatment times are similar, the There do not appear to be any specific
combination of the modalities can save contraindications for combination therapy
time and effort (even without addi- other than those for the individual modalities.
116 Handbook of Practical Electrotherapy

DOSIMETRY OF ULTRASOUND THERAPY the body surface, known as the half-value

Appropriate dosage in ultrasonic therapy has distance. This attenuation takes place due
been a subject of controversy ever since the to reflection, absorption and refraction of
inception of this modality in therapeutic the ultrasound energy, as it travels from
practice. Theories abound regarding the the transducer, through different
propriety of space-averaged or time-averaged mediums, to the target tissue.
intensities, the effectiveness of pulsed or • To calculate the appropriate dosage the
continuous mode of application and the half- first thing that must be taken into consi-
value distances. For the want of concrete deration is the location or depth of the
scientific evidence, the dosing parameters target tissue, i.e. the number of tissue
have for long been based on the clinical layers or interfaces the beam of ultrasound
experience of individual therapists. Majority must cross before it can reach the target.
of established authors have documented only Thick tissue cover will mean more attenua-
the general principles and guidelines for dose tion of the ultrasound energy and vice
calculation in ultrasound therapy, leaving the versa.
actual dosing to the imagination and expe- • Hence, for superficial targets lower
rience of the individual practioner. In this intensity and for deeper targets higher
section I have made a humble attempt to intensities of ultrasound will be needed.
simplify this ambiguous picture for the • The intensity of the ultrasound can be
beginner. further modulated to suit the clinical
condition being treated by using conti-
Points to Ponder nuous or pulsed beam of ultrasound
• The space-averaged intensity of ultra- energy.
sound is the net output of ultrasound • For acute conditions the mechanical and
energy per square centimetre area of the the biological effects are preferred, hence
transducer, expressed as Watts/cm sq. This pulsed mode of ultrasound given for
is the most commonly used dosing format shorter periods will be most suitable.
of ultrasound therapy, displayed on the • For chronic disorders the heating effect is
analogue or digital metre available on the desirable, hence continuous mode of
ultrasound therapy equipment. ultrasound applied over longer durations
• The time-averaged intensity of ultrasound will be appropriate.
is the total output of ultrasound energy • Dosage of ultrasound depends on:
over a specific period of exposure. This is 1. Mode—Pulsed mode delivers less
calculated by multiplying the space- energy than continuous.
averaged intensity with the total surface 2. Frequency—Lower frequency has
area of the transducer and the duration of greater penetration than higher.
exposure in seconds. 3. Intensity—Usually used space-aver-
• The intensity of the ultrasound beam is aged intensity measured in Watts/sq
reduced by half at a certain depth below cm.
 Therapeutic Ultrasound (US Therapy) 117

4. Duration—Duration of treatment is Dosage for Ultrasound Therapy

calculated in minutes and varies in
For the young practitioner Table 11.1 may act
direct proportion to the size of the area
as a guideline, till such time he/she can build
being treated. Always restrict the up his/her own clinical repertoire.
maximum area covered to three times
the surface area of the transducer head, Points to Ponder
i.e. if the transducer head is 5 sq cm. in
area then maximum area covered for • Therapeutic ultrasound is commonly
adequate insonation in one sitting applied through direct contact method
should not exceed 15 sq cm. Larger using a coupling medium to eliminate air
areas may be divided into grids; each space between the treatment head and the
of 15 sq cm and then treated one after skin surface.
the other. • In direct contact method, as far as possible,
5. Treatment should be repeated once or the patient should be positioned in such a
twice daily for acute lesions and less way that the transducer head is applied
frequently for chronic lesions. vertically downwards on the body surface

Table 11.1: Dosage for ultrasound therapy

Condition Dosage in Mode Duration in
Watts/cm sq minutes
Abscess of soft tissue 0.5–2 Pulsed 8–10
Bursitis 0.6–1.5 Continuous 8–10
Cellulitis 1–2 Continuous 10–15
Myalgia 2–3 Continuous 10–15
Neuralgia 1–3 Continuous 10–15
Periarthritis of shoulder 0.5–3 Pulsed/Continuous 10–15
Radiculitis (root pain) 1–2 Continuous 10–15
Intermittent claudication 1–3 Continuous 5–20
Lumbago 1–3 Continuous 10–15
Lymph-oedema 0.5–2 Continuous 10–15
Muscular rheumatism 0.8–3 Continuous 10–15
Sciatica 1–2 Continuous 10–15
Stump neuroma 2–3 Continuous 10–15
Ulcer 1–3 Continuous 10–15
Coxydanea 1–3 Continuous 10–15
Myositis ossificance 1–2 Continuous 10–15
Polyarthritis 1–2 Continuous 5–15
Sudecks osteodystrophy 1–3 Continuous 10–15
Tenosynovitis 1–2 Continuous 10–15
118 Handbook of Practical Electrotherapy

being treated. The weight of the treatment • Other infrequently used methods of
head will contribute to the pressure applications are water bag and water bath
applied by the therapist, holding the methods.
treatment head firmly against the body • New methods of application of ultra-
surface. This position will also make sure sonic therapy, such as phonophoresis and
that the coupling medium does not trickle combination therapy is gaining accep-
down the surface of the skin. tance.
 Therapeutic Cold 119

12
Therapeutic Cold
DEFINITION BIOPHYSICS
Localised cooling of the body surface to • Therapeutic cold can be applied to the skin
extract body heat from the underlying tissues, through evaporating or conducting moda-
by evaporation or conduction, in order to lities
lower local tissue temperature and thereby • Volatile liquids, when brought in contact
provoke therapeutically useful physiologic with warm objects, extract heat of vapori-
thermoregulatory reaction is known as cold sation from the underlying tissue. Most
therapy or cryotherapy.1 common evaporative cold modality used
in the sports field is Furio-Methane sprays
DISCUSSION • Cold substances, when brought in physical
contact with warm body tissues, extract
Generalised cooling of the body, commonly heat through direct molecular energy
known as hypothermia, is used to lower the transfer or conduction. Ice is the conduc-
temperature of the whole body. As a result of tive cold modality most commonly used
hypothermia the basic metabolic rate, pulse for therapeutic purpose. Ice can be applied
rate, respiratory rate, venous blood pressure to the body in the form of crushed ice
and therefore the oxygen demand in the packs, cold water bath or ice massage.
tissues fall to a minimum. There is a rise in Commercially available reusable cold
blood flow to internal organs, cardiac output, packs can also be used, after cooling it to
stroke volume and arterial blood pressure. the appropriate degree in a freezer
Hypothermia is used during major surgical • On application of such cold source, heat is
interventions to lower the oxygen demand in drawn @ 333 joules/gram of ice, by
tissues and give more operating time to the conduction from the subcutaneous tissues
surgeons during open-heart surgeries. through the skin, to convert the ice to
Localised cooling of tissues, commonly water. This causes drastic drop in the tissue
known as cryotherapy is used in physiotherapy temperature
as an anti-inflammatory and analgesic agent, • The drop in tissue temperature, i.e. the
effective in musculo-skeletal disorders. degree of cooling achieved in the tissues
120 Handbook of Practical Electrotherapy

depends on the rate and duration of sia or numbness is experienced. In addition

energy extraction, which in turn depends to decreasing sensory and motor nerve
on the following factors. conduction velocity, cryotherapy decreases
1. The difference in temperature between pain through the stimulation of endorphin
the coolant and the tissue. Greater the release, reduction in metabolism, and counter
temperature gradient, faster the irritation. Furthermore, the decrease in
cooling. sensory input inhibits the stretch reflex and
2. The heat conduction property of indi- aids in reducing muscle spasms. Reduction in
vidual tissues. Cooling is greater in metabolism to healthy tissues surrounding
tissues with large water content, i.e. the injured area is beneficial in order to
muscles or blood and relatively less in prevent secondary hypoxia.1 Following acute
tissues like skin or subcutaneous fat injury, the build-up of fluid and proteins and
which act as insulators. increased interstitial pressure create oedema,
3. Temperature of tissue subjected to which compromises circulatory integrity,
localised cooling will continue to drop placing the surrounding tissues at risk for
till the heat generated in the tissue hypoxia. Slowing tissue metabolism reduces
equals the heat extracted from. energy and, therefore, oxygen requirements
4. The total surface area of the body of the surrounding tissues, enabling them to
subjected to cooling is directly propor- survive without hypoxic damage.
tional to the extent of heat loss. In terms of motor performance, sensory
5. The skin temperature can be lowered changes will result in a decrement in manual
significantly with short period of dexterity and fine motor activity. However,
cooling, though it takes much longer to most skilled or gross motor tasks performed
lower the temperature of the deeper immediately following cold application will
tissues like muscles or joints.2 not be impaired.
• Different body tissues respond differently
Physiological Effects of Localised Cooling to localised application of cold
The therapeutic benefits of cold post-acute • Skin cools the fastest with maximum drop
injury, postoperatively, and during rehabili- in temperature
tation are well documented. The physiological • Subcutaneous tissue cools more slowly
effects of cold include a decrease in tissue than the skin and shows moderate drop
temperature and metabolism. Circulation is in temperature
also decreased as a result of vasoconstriction • Muscles and bones show minimal changes
and increased blood viscosity. Increased tissue in temperature, even on prolonged expo-
and synovial fluid viscosity will create muscle sure to cold
stiffness and slightly impair muscular effi- • Dramatic vasoconstriction of skin capil-
ciency. Pain and muscle spasms are reduced laries creates blanching (white colour) of
as a result of cryotherapy’s effect on the the skin at the point of contact with the
nervous system. Cold reduces the rate of cold source. The skin over the surrounding
firing in nerves to the point that sensory nerve area turns red (hyperaemic) due to hista-
conduction is blocked and thermal anaesthe- mine mediated rebound vasodilatation
 Therapeutic Cold 121

• If the exposure to cold is prolonged, Lewis inhibition of sympathetic, sensory and

hunting reaction sets in. Lewis hunting motor conduction.
reaction is alternate cyclic vasodilatation 3. Increased blood viscosity—Due to increa-
and vasoconstriction, while the body sed adherence of RBC to each other and
searches for the mean volume of blood walls of blood vessels.
flow to the cold area to maintain minimum 4. Increased strength of muscle contraction—
sustainable circulation to meet the meta- Due to facilitation of alpha neuron
bolic demand of the tissues activity, application time < 1-5 min.
• Application of local cooling of the body
tissues trigger following set of negative Adverse Physiological Effects of
physiological responses. Localised Therapeutic Cooling
1. Reduced blood flow—Due to vasocons- • Hypersensitivity to cold is mostly related
triction of arteries, arterioles and to release of histamine leading to
venules resulting from sympathetic 1. Cold Urticaria- red wheals on the skin
adrenergic activity. associated with sever itching.
2. Reduced capillary permeability—Due to 2. Flushed face.
less fluid in the interstitial tissue. 3. Puffy eyelids.
3. Reduced elasticity of non-elastic soft 4. Respiratory distress.
tissue—Due to decreased elasticity of 5. Anaphylactic shock and syncope.
collagen.
4. Reduced metabolic rate—Due to inhi- TECHNIQUES OF THERAPEUTIC
bition of cellular oxidation. COOLING
5. Reduced muscle spasm—Due to inhi-
bition of tonic extrafusal activity. There are many cryo-therapy modalities
6. Reduced strength of muscle contraction— available. These include the ice pack, cold
due to inhibition of blood flow to the pack, ice massage, cold whirlpool, cryo-cuff,
muscle and increased muscle protein cold spray, cryo-stretch, and cryo-kinetics
viscosity, on application time > 5 to 10 Different Methods of Therapeutic Cooling
min
7. Reduced spasticity—Due to reduce Ice Packs
muscle spindle and gamma motor • It is the most cost effective method of
activity therapeutic cooling for joints and smaller
• Application of local cooling of the body body segments like the hands, feet, knee,
tissues trigger following set of positive elbow, shoulder etc.
physiological responses • This method of cooling can be practiced
1. Increased joint stiffness—Due to dec- at the clinic or at home, with minimum
reased extensibility of collagen. inputs in terms of infrastructure, equip-
2. Increased pain threshold—Due to inhi- ment and recurrent expenditure.
bition of A-delta and C fibres (spinal • A standard refrigerator, ice tray, polythene
gate control mechanism). Breaks the bags, hand towel and water are all that is
pain spasm vicious cycle through needed to give effective ice packs.
122 Handbook of Practical Electrotherapy

• Ice cubes are placed in the clear polythene or wooden spatula is placed in the cup of
bag, wrapped in moist towel to form a water prior to freezing to provide a
pack. The pack should be large enough to convenient handle for the ice cone.
cover the target area. • The ice cone is applied directly to the skin
• The pack is applied to the body and then over the trigger point and massaged with
covered with a dry towel to prevent rapid firm pressure, in a concentric circle just like
melting of ice. Heat transfer takes place by an ultrasound transducer.
conduction of heat from the body tissue • The maximum area suitable for ice
to the ice packs to supply the latent heat massage in one sitting should not exceed
of melting to the ice. 4” × 6”. The rate of movement of the ice
• The part to be treated is exposed and cone over the skin should not exceed
checked for any cuts, bruises, discolora- 2”/second.
tion, loss of sensation and skin diseases. • The part to be treated is exposed and the
• Average treatment time with ice packs is skin should be checked for any cuts,
10 to 20 minutes. bruises, discoloration, and loss of sensation
• The melted ice is retained by the sealed and skin diseases.
polythene bag and does not cause a mess. • During the application of ice massage the
patient will initially feel cold sensation
Ice Towels followed by burning, aching and finally
• This is the method of choice for cooling of numbness of the part being treated.
large, flat, predominantly muscular areas • Treatment should be continued till the part
like the back, thigh and calf. becomes numb. The duration of treatment
• In this method the equipments needed are is 5 to 10 minutes.
the same as in case of ice packs. Water is • Massaging ice over superficial nerves like
added to crushed ice in a tub to form slush. the ulnar nerve at the medial epicondyle
• Two towels, large enough to cover the of elbow or common peronial nerve at the
target segment are soaked in this slush. neck of the fibula is contraindicated as it
One towel is wrung out and placed in two may interfere with the nerve function.
folds on the part to be treated.
• The towels should be exchanged after Commercial Cold Packs
every 1 to 2 minute, till 15 to 20 minutes. • This is the most hassle free form of cold
• The part to be treated is exposed and the therapy, since there is no need to make ice
skin should be checked for any cuts, packs, slush or cones, as well as, no mess
bruises, discoloration, and loss of sensation created by melting ice.
and skin diseases. • Commercial cold packs are made of vinyl
casing filled with silica gel, available in
Ice Massage different sizes ranging from 6” × 8” to
• This is the method of choice for cooling 10”× 14” and are quite expensive as
much-localised spots like a trigger point. compared to ice packs described above
• A cone of ice is frozen keeping water in a and therefore are suitable for hospital
paper cup in the freezer. An ice cream stick settings only.
 Therapeutic Cold 123

• Before application, the packs are cooled to • Number of strokes should not exceed 3-5
freezing point or below in a deep freezer. only, to avoid cold injury to the skin.
• The part to be treated is exposed and the • In case of muscle spasm, the target muscle
skin should be checked for any cuts, should be stretched to the limit of pain free
bruises, discoloration, loss of sensation, range, during and in between each appli-
etc. and for skin diseases. cation of spray. The patient must be
• One towel, folded width wise, is soaked encouraged to perform active exercises of
in warm water and then wrung out to the affected muscle immediately after the
remove excess water. The moist towel is coolant spray.
then placed over the part to be treated and • When a crucial soft tissue like the ligament
the pack is placed on the moist towel. A or tendon has been injured, the painful site
dry towel folded width wise is placed on should be sprayed 2 to 3 times and the
top of the pack to slow down warming and stabilised with elastic tape/bandage/strap
the whole thing secured with a Velcro to prevent aggravation of the trauma
strap. during further activity.
• The treatment time is 10 to 20 minutes. • It must be realised that coolant spray is
only a temporary pain relieving measure
Coolant Spray
that allows the athlete to complete the
• It is the cooling modality of choice for use sporting event. It is essential for the
in the sporting arena, where rapid cooling therapist to examine the injured part
is needed in a very short time to provide thoroughly after the event to identify any
temporary relief of pain and spasm, to serious and lasting damage to the involved
allow the athlete to continue to perform. tissues and take appropriate remedial
• A non-toxic, non-inflammable, volatile measures.
liquid in form of aerosol spray is used for
this purpose. Contrast Bath
• The coolant is sprayed on the skin to
reduce muscle spasm and for desensiti- Definition: It is alternating immersion of body
sation of injured soft tissues or trigger segments, like hands and feet, in warm and
points. cold water, to produce alternating vasodila-
• Heat is extracted from the body tissue for tation and vasoconstriction in the peripheral
the evaporation of the volatile liquid. blood vessels to provide vascular exercise to
• To apply the coolant, the spray can is first the part. For the patient exhibiting psycho-
shaken hard and then inverted, holding logical intolerance to cryo- kinetics, contrast
the nozzle 18” away from the skin. baths combined with active exercise may be
• A thin layer of coolant is sprayed at an a treatment alternative.
angle of 20 to 30° in sweeping strokes to Traditionally, contrast baths consists of
cover the skin over the affected area. alternating immersion of the injured body
• The speed of the strokes should be 3-4”/ part in hot (106°F) and cold (50°F) water over
second. The liquid should be allowed to a period of 20 to 30 minutes. Immersion time
dry completely before applying any is typically 4 minutes of hot followed by 1
subsequent strokes. minute of cold. The comforting sensation of
124 Handbook of Practical Electrotherapy

the warm water, combined with the limited • The treatment commences with hot water.
exposure to the cold water, may enable cold- The part to be treated is first immersed in
intolerant patients to initiate active exercises hot water for 6 to 10 minutes at a stretch.
earlier in their rehabilitation program. Active If the water feels too hot, some tap water
movement can be incorporated into contrast may be added to the hot tub or if it is not
baths by adding active exercises as a third warm enough, some more hot water may
step, immediately after the 1-minute cold be added to the tub.
immersion, just before re-immersing the part • After soaking in warm water the part is
into the hot water. This three-step cycle would transferred to the cold tub and allowed to
then be repeated over a series of four to five soak for 1 minute. If the water does not
times, ending the treatment with cold water feel cold enough, some more ice cubes may
immersion. be added to the tub.
Controversy does exist, however, regard- • The part is then transferred to warm water
ing the universally accepted, but never and allowed to soak for 4 minutes.
demonstrated theory, that oedema reduction • The cyclic immersion in hot and cold water
during contrast baths occurs as a result of the in the ratio of 4:1 is continued for 30 minu-
“pumping mechanism” induced from the tes.
alternation of vasodilatation and vasocons- • The treatment cycle ratio of 4:1 is variable,
triction. depending upon the underlying disorder.
The contrast bath serves as an appropriate In acute conditions, the ratio may be
treatment alternative, more in the sub-acute, changed to 2: 1.
rather than acute, phase of soft tissue inflam- • In chronic conditions with indurate
mation. oedema, the contrast bath treatment
Two-way heat transfer takes place in this should commence and end with hot-water
method, i.e. by conduction of heat from the soak. In acute conditions with significant
body tissue to the cold water and from the effusion, treatment should be terminated
hot water to the body tissue. with cold-water soak.
• Two plastic containers or washtubs, large • Contrast bath is indicated for any condi-
enough to hold the body part, are filled tion that needs stimulation of peripheral
with warm and cold water. circulation. It is a modality of choice for
• The temperature of the hot water should acute and chronic musculo-skeletal inju-
be 40 to 45°C and cold water around 5 to ries, like sprain, strain, post fracture
10°C. While instructing the patient for stiffness and in peripheral vascular dis-
home programme, explain for the ease of orders like lymph-oedema, vasculitis,
understanding that the hot water should varicose veins and Burger’s disease.
be as hot as can be tolerated on the • Losses of thermal sensation and arterio-
immersed part and the cold water should sclerosis in advanced stage with chronic
feel ice cold to the skin, without any insufficiency of blood supply are strict
discomfort on prolonged immersion. contraindication to contrast bath.
 Therapeutic Cold 125

APPLIED COLD THERAPY: the application of therapeutic heat. Further-

CRYO-KINETICS more, tissue gliding during early mobilization
minimizes the risk of adhesions while concur-
The combination of therapeutic cold and
rently facilitating scar tissue remodelling.
exercises, to restore pain-free function, is
Finally, active motion helps the patient
known as cryo-kinetics.3
overcome the neural inhibition that frequently
Indications and Advantages of accompanies post injury pain and inflam-
Cryo-kinetics mation.
Cryo-kinetics is relatively inexpensive and
Cryo-kinetics consist of numbing an injured easy to implement. Therefore, it is practical
body part to allow the patient to tolerate for almost every rehabilitation setting.
progressive, active exercise. This active Depending on the mode of cryotherapy
exercise is subsequently followed by reappli- chosen, equipment needs may include: buc-
cation of cold and the series is repeated a kets, basins or whirlpools, ice that is prefer-
number of times. Cryo-kinetics dates back to ably crushed, cold packs, ice bags or frozen
the 1960s when rehabilitation specialists at ice cups, towels, a rubber mat or no slip
Brooks Army Medical Hospital reported an surface, and toe or finger caps if needed.
80 per cent success rate in returning soldiers Therapeutic equipment needed vary depend-
to unrestricted duty within 3 days of imple- ing on the individualized exercise program-
menting an aggressive cryo-kinetic program. mes.5,6
Perhaps the most appropriate use of cryo-
kinetics is treating patients with acute joint Treatment Guidelines for Cryo-kinetics
sprains in which range of motion (ROM),
weight-bearing tolerance, and functional Step One
activity tolerance are limited by pain and Prior to initiating treatment, the patient must
oedema. Following an acute injury, pain often be given a thorough explanation of the
restricts motion, which prevents patients from purpose and expectations from the treatment.
returning to their work or sport. Cryo-kinetics Patients must be forewarned about the
speeds the recovery process by enabling discomfort associated with cryotherapy while
patients to participate in pain-free controlled emphasizing the necessity of the temporary
mobilization sooner than would normally be pain in order to achieve the desired outcome.
tolerated. Cryo-therapy decreases pain to The thermal sensation of the patient must be
allow the patient to receive the benefits of checked for normalcy before application of
active motion that may otherwise not be cold.
tolerated. The muscle-pumping action of
active motion aids in removal of dead tissue, Step Two
pain-inducing substances, and excess fluid Patients must be instructed on how to
lingering at the injured site. Knight reports differentiate among the different types of pain
this active pump is aided by exercise-induced and discomfort that they may experience
vasodilatation brought about that actually during the treatment. They need to be able to
surpasses circulatory increases stimulated by choose from pre-existing pain, due to their
126 Handbook of Practical Electrotherapy

injury or pathology, from cold-induced pain, wear off and sensation returns to the part.
as a result of the sensory changes due to the Patients should attempt to perform five to six
cold application. The numbing process, which sets of active exercise, separated by periods
begins with sensation of cold, followed by of cold application to restore numbness.
tingling, burning and aching, finally leading Exercise progressions in cryo-kinetics are
to anaesthesia. On the other hand, exercise- similar to those in more traditional thera-
induced pain, of an anaesthetized foot may peutic exercise programs.
mean the exercise is inducing additional tissue
damage. Pain-free motions are crucial during Exercise-Specific Guidelines
the exercise component of cryo-kinetics. • Non-weight-bearing, pain-free, active
Exercise-induced pain is a signal to the ROM should start with single plane and
rehabilitation specialist that the particular progress to multi-planar motions. Postural
exercise is too strenuous and needs to be repositioning and active-assisted stretch-
modified if possible or discontinued. The ing may also be introduced for the patient
patient must be able to differentiate between with low back pain
the return of pre-numbing discomfort and • The weight-bearing exercises include a
exercise-induced pain. progressive shifting from partial weight
bearing to full weight bearing, unilaterally
Step Three on the involved lower extremity (LE).
Weight-bearing activities can also be
Treatment is initiated by numbing the body
introduced into upper extremity (UE) by
part with a chosen method of cryotherapy. Ice
having the patient lean on a table or wall.
immersion, ice water bath or whirlpools, ice
• ROM exercises in weight bearing, includ-
massage, and cold packs are all considered
ing closed kinetic chain exercises (CKC),
acceptable means for cryo-kinetics. The length
wall push-ups; biomechanical ankle
of time for the cold application varies depend-
platform board (wobble board) exercises
ing on the modality chosen and the body part are introduced progressively. If the patient
being treated. The patient reporting numb- has not achieved full ROM in the ankle,
ness of the part, determined by a loss of tactile weight-bearing stretches such as a stand-
sensation, serves as the guide for the duration ing TA stretch may be incorporated into
of treatment. The initial numbing takes this phase of rehabilitation
anywhere from 10 to 20 minutes during the • Progression is made to ambulation, static
first cold application before exercise. Cooling cycling, stair climbing and climbing stairs
the part after exercise takes less than 5 minutes or ramps. Training should proceed cautio-
in most cases. usly, with a strong emphasis on proper
form. If the patient is not able to tolerate
Step Four
full weight bearing, additional tissue
Once numbness is established, active exercise damage may occur if the exercises are
within the pain free range may commence. progressed too quickly or performed
Each exercise set should last approximately 2 incorrectly. Lower extremity activities
to 3 minutes, until the numbness begins to should be performed with both shoes off,
 Therapeutic Cold 127

as a self-imposed leg length discrepancy exercises Progression can be objectively

may contribute to faulty biomechanics and recorded as an increase in demonstrated
induce additional damage. Furthermore, ROM, weight- bearing tolerance, or move-
caution must be taken during LE cryo- ment speed. Functional progress is de-
kinetics to ensure that the limb is ade- monstrated through the documented
quately dried before exercises are per- advancement from basic functional skills
formed. Exercise and gait training must be such as ambulating, to the more complica-
performed on a no slip surface such as a ted, sport-specific skills like sprinting and
rubber mat. Increasing the speed or jumping.4
resistance to the movements makes prog-
ressions in the exercises Step Seven
• Resistive exercises restore muscular
• The final phase of cryo-kinetics involves
strength and power and may consist of
allowing the numbness to wear off while
progressive resistive exercises (PREs)
functional activity continues. This enables
using weights, bands, or other available
the therapist to assess the patient’s exercise
equipment. Pain-free heel walking and toe
tolerance. At this stage, sport or work
walking utilize the patient’s body weight
specific activities can be performed in
as resistance to movements, in a safe and
more realistic settings such as the work
controlled manner
places or the practice field. During this
• For Progression into functional activities
phase of rehabilitation, braces, taping,
of daily living or sports, specific activities
protective shoes may be utilized to in-
should be introduced into the cryo-kinetic
crease safety and support.
program at safe intensities, before attempt-
ing them at pre-injury intensities. For a Follow-up
sedentary person, high speed walking may
progress to jogging and then to slow • Ideally, cryo-kinetics should be performed
running. For athletes, the running speed two to three times a day for the patient
can be increased progressively until they whose main goal is to return to sport or
can tolerate short sprints. work, as soon and as safely as possible.
The therapist should teach the patients
Step Five how to carry out the cryo-kinetic program
• As numbness wears off, patient’s sensation at home. An adequate quantity of ice is
of the pain will return. This is the signal to needed. The patient can use own body
reapply the cold and re-numb the affected weight through CKC for the resistive
area. Re-numbing generally takes between exercise for the home program. In the
3 and 5 minutes. sports setting, the athletic trainer can
readily carry out the treatments. Likewise,
Step Six for a therapist working in an inpatient
• The focus of cryo-kinetic documentation hospital facility treating postoperative
should be on the description and the patients or running an outpatient work
amount of time spent on the individual hardening program, cryo-kinetic treat-
128 Handbook of Practical Electrotherapy

ments, done twice to three times daily are • When applied in chronic pain, therapeutic
realistic and strongly encouraged. cold helps activate the gate control mecha-
The suitability of cryo-kinetics for a given nism of pain relief through sensory
patient depends on the location and extent stimulation. The intense cold sensation
of the injury. For example, following a also stimulates the release the indigenous
minor ankle sprain, cryo-kinetics can be opiates like beta-endorphins in the brain,
initiated within the first 24 to 48 hours. which modulates the pain receptors at the
However, severe joint sprains may be cortical level.
unsafe for the cryo-kinetics. • Reduces muscle spasm and spasticity
through stimulation of cutaneous recep-
Points to Ponder
tors and muscle spindles, which inhibits
The physiological effects of local cooling are: stretch reflexes of the spasmodic/spastic
• Perception of cold, tingling, burning and muscle.
pain due to stimulation of thermal and
pain receptors Techniques of Local Cooling
• Localised vasoconstriction followed by
rebound vasodilatation, which continues • Preparation of patients: Explain the reason
in a cyclic manner due to Lewis hunting for, intensity desired and the nature of cold
reaction, creating a vascular pumping application to the patient. This will some
action. Reduction of blood flow in the soft fear and misconception towards applica-
tissue is the long-term result tion of cold. The patient is told what sensa-
• Lowered metabolic rate as per Van’t Hoff’s tion to expect and to inform the therapist
law, resulting in reduced oxygen consump- if there is any increase in pain. The patient
tion, production of metabolites, cellular should be interviewed briefly to rule out
activity and rate of healing any general contraindication like hyper-
• Inhibition of peripheral nerves due to tension or cardiac problems and the area
reduced NCV, resulting in reduction of to be treated is examined for any local
pain sensation, tone and spasm of skeletal contraindication to application to cold.
muscles and the dexterity and speed of • Preparation of the part: The part to be
fine motor activity. treated should be exposed and positioned
The therapeutic uses of local cooling are: with adequate support. The skin should be
• When applied to recent trauma, therapeu- examined for abrasions, skin disease, loss
tic cold limits blood loss due to vasocons- of sensation etc. Sensitive skin may be
triction and increased viscosity of the coated with liquid paraffin, before immer-
blood, controls formation of soft tissue sion in ice water bath. In acute trauma with
oedema or effusion in joints, reduces pain swelling, the part should be arranged in
by inhibition of conduction in pain carry- elevation before applying cold packs.
ing nerve fibres, reduces metabolic rate of • Preparation of the cold source: The tempe-
injured tissue and thereby restricts tissue rature of the cold source must be carefully
necrosis. monitored before and during treatment.
 Therapeutic Cold 129

This is particularly important while using Alternatively faradism under pressure

ice-bath. The condensation from the cold may be applied for 15 to 30 minutes to
source must be mopped up from plinth or mobilise the tissue fluid just before
working surface with an absorbent cloth application of cold therapy.
or paper towel. 5. The condition of the skin must be checked
periodically (every 2-3 minutes) during the
Application of Therapeutic Cold treatment, to monitor the onset of vaso-
constriction and vasodilatation. If hyper
1. The cold packs should be held firmly
reaction occurs the treatment should be
against the skin for optimum heat transfer. terminated immediately.
Every 2-3 minutes the packs should be 6. After completion of the treatment the
moved slightly on the skin the avoid patient should be advised to avoid heat
formation of ice layer on the skin, which exposure or hot bath for at least two hours.
may cause frostbite. 7. The patient should be asked to monitor the
2. The desirable temperature of cold therapy skin condition closely for the next 24 hours
should not be less than 4 to 6°C. To lower and to report any adverse changes before
the intensity of cold, keep the pack loosely the next sitting.
on the skin. Loosely held packs retain air
pockets between the cold pack and the REFERENCES
skin which act as insulator and therefore 1. Knight KL. Cryo-therapy in Sport Injury
restrict the intensity of cooling. Management. Champaign, Ill: Human Kinetics;
3. While giving ice water bath treatment ask 1995:3-18,59-71, 77, 107-130, 175-177, 217-32.
2. Barnes L. Putting injuries on ice. Physicians
the patient to move the part periodically Sports Med 1979;7(6):130-36.
in the bath. This movement will dissipate 3. Denegar CR. Therapeutic Modalities for Athletic
the heat faster and result in uniform Training. Champaign, Ill: Human Kinetics;
cooling. 2000;104-11.
4. Gaydos HF, Dusek ER. Effects of localized hand
4. Cold compression technique is very cooling versus total body cooling on manual
effective in reducing swelling. This type of performance. Journal of Applied Physiology
cooling is applied through an intermittent 1958;12:376-80.
compression machine with cold fluid 5. Hayden CA. Cryo-kinetics in an early treatment
program. Physical Therapy. 1964;44:990-93.
instead of air in the compression sleeve. 6. Prentice WE. Therapeutic Modalities in Sports
The part must be kept in elevation during Medicine. Boston: WCB/McGraw-Hill 1999;
such treatment for getting best results. 187-89.
130 Handbook of Practical Electrotherapy

13
Therapeutic Light
(Actinotherapy/Heliotherapy)
And God said, “Let there be light”. In physiotherapy, light energy in the form
of ultraviolet, infrared and laser are used for
The light in the Bible means both visual and
therapeutic purpose. Since all types of light
non-visual light. Of all the electromagnetic
radiations striking the earth, approximately originate from the sun, this form of therapy
50 per cent is visible light, having wave- is called Heliotherapy (Helios means sun in
lengths between 400 and 700 nanometres. (A Greek) or Actinotherapy (Actinos means light
nanometre (nm) is the standard measurement in Latin).
used to express wavelength of electro-
magnetic radiation. It is equivalent to one HISTORICAL PERSPECTIVE
billionth of a meter in length). Helios is the god of sun in Greek mythology.
Electromagnetic radiation comes in many Heliopolis, an ancient Greek city was famous
forms. The most familiar among them is for its temples of sunlight healing. This is
visible light. Other forms include X-rays, where Heliotherapy or science of therapeutic
ultraviolet (UVR), infrared, microwave and
sunlight was born. Herodotus, the father of
radio waves. Daylight consists of direct solar
heliotherapy wrote that exposure to the sun
radiation, diffused radiation from the sky (sky
is essential for a sick persons who needs to
shine) and wavelengths reflected from
restore his health. In winter, spring and
surroundings, such as buildings, etc.
autumn, the patient should permit the rays
Generally the moisture in the atmosphere
absorbs a great deal of ultraviolet radiation of the sun to fall upon him; but in summer,
and even more so by smoke and dust parti- because of the excessive heat, this method
cles. should be used in moderation.
Visible light has seven colours, violet, In 1877, Downs and Blunt discovered the
indigo, blue, green, yellow, orange and red, dramatic ability of sunlight to destroy and
which are only a fraction of all wavelengths provide for an effective means of treating
known to mankind. Colour combinations and bacterial infections. Another famous practi-
blends of hue in this visual range can exceed tioner of heliotherapy was Auguste Rollier
100 million. MD, whose clinic was at 5,000 feet above sea
 Therapeutic Light (Actinotherapy/Heliotherapy) 131

level. Dr. Rollier stated that his patients would 3. Increase RNA and DNA synthesis helping
get the best results if they received the highest damaged cells to be replaced more
amount of ultraviolet light at this altitude. promptly.
Ultraviolet intensity increases 4% to 5% every 4. Stimulate fibroblastic activity, which aids in
1000 feet ascended. He apparently substan- the repair process. Fibroblasts are present
tiated incredible results, which were pub- in connective tissue and are capable of
lished in his book La Cure de Soleil, i.e. Curing forming collagen fibres.
with the Sunlight. 5. Stimulate tissue granulation and connec-
Dr. John Otto, the father of modern tive tissue projections, which are part of
photobiology noted that sensible exposure to the healing process of wounds, ulcers or
sunlight is not only safe but is desirable for inflammation.
good health. Life on Earth evolved under 6. Stimulate the release of adenosine triphos-
natural sunlight and has existed for billions phate (ATP). ATP is the major carrier of
of years under the full spectrum of light energy to all cells. Increases in ATP allow
(visual and non-visual) that it contains. Many cells to accept nutrients and get rid of
prehistoric tribes and even entire civilizations waste products faster by increasing the
like the Mayans and the Persians worshiped energy level in the cell.
the sun for its healing powers, using its light 7. Increase lymphatic drainage. Research has
to treat physical and mental illnesses. Though shown that the lymph vessel diameter
exposure to UV light in large amounts is and the flow of the lymph can be doubled
harmful; in trace amounts, as in moderate and the venous diameter and the arterial
amounts of natural sunlight, it acts, as a life- diameters can also be increased with the
supporting nutrient that is highly beneficial. use of light therapy. This means that both
liquid and protein components of
WHAT DOES SUNLIGHT THERAPY oedema can be evacuated at a much
ACTUALLY DO? faster rate to relieve swelling.
Sunlight Therapy can have the following effects 8. Relieve pain. Light therapy is successfully
on the human body: used in pain management, dermatology
1. Increase circulation by formation of new and rheumatology with excellent thera-
capillaries to replace damaged ones to peutic effects.
speed up the healing process by carrying 9. Stimulate acetylcholine release and other
more oxygen as well as more nutrients parasympathetic effects.
needed for healing and carry waste 10. Increase phagocytosis, as an important part
products away. of the infection fighting process. Destruc-
2. Stimulate the production of collagen, the tion of the infection and clean up must
most common protein found in the body occur before the healing process can take
essential for repair of damaged tissue and place.
to replace old tissue. By increasing 11. Induce thermal effect, which raises the
collagen production less scar tissues are temperature of the tissue being treated,
formed at the wounds. to kill or disable bacteria and viruses.
132 Handbook of Practical Electrotherapy

Discussion emitted with a wavelength bandwidth of

180 to 12000 nm. These contain visible light
Modern scientific research claims that sun-
as well as invisible radiations like UVR and
light; especially ultraviolet rays can be
Infrared. Such radiations are governed by
hazardous to our body. Controversy exists
following laws of physics.
over potentially-harmful effects of the invi-
• Lamberts cosine law, which states that, “the
sible ultraviolet frequencies (wavelength 100
angle of incidence of radiation determines
to 400 nm), which equal 10 per cent, and
the amount of radiant energy absorbed.”
infrared frequencies (wavelength over 700
In terms of therapeutic application it
nm), which are 40 per cent of all radiation
means that optimal absorption the radia-
reaching earth. Of course, the fact remains that tions should occur when the rays are
without ultraviolet and infrared our world perpendicular to the skin surface being
would not be the same. Infrared provides us treated.
with the required heat that keeps us warm. • Inverse square law, which states that, “ the
Ultraviolet provides us with the ability to intensity of radiation varies inversely with
fight off germs in the air (UVC), creates skin the square of the distance between the
pigmentation as a natural protector (UVB) source of radiation and the surface it falls”
and helps in our vitamin and mineral absorp- In terms of therapeutic application it
tion capabilities (UVA). UVC are the shortest means that if the source of radiation is
ultraviolet rays and our atmosphere and the moved halfway closer to the skin it’s
ozone layer absorb virtually all of these intensity will increase four times. Hence
frequencies. The remaining UV light that to increase or decrease the intensity of any
reaches the ground is about 10 per cent UVB type of therapeutic light the distance
and 90 per cent UVA at midday. Overexposure between the emitter of radiation and the
to sunlight may cause varying degrees of skin should be increased or decreased.
sunstroke, heat stroke or sunburns and such
symptoms as headache, undue fatigue or TYPES OF THERAPEUTIC LIGHT
irritability. On the other hand, properly Apart from natural sunlight, in physiotherapy,
applied sunshine act as a powerful tonic, three types of light energy are used for
helpful in increasing general powers of treatment of different disorders. These are
resistance and promoting mental and physical ultraviolet radiations, infrared radiations and
development. For this reason the duration and LASER. Each of these light energy have
extent of exposure to sunshine should be specific effects on the physiology of the
carefully graduated and those who do not human body and is used to correct specific
pigment efficiently or easily should be disorders.
warned to be especially careful.
ULTRAVIOLET RADIATION THERAPY
PHYSICS OF THERAPEUTIC LIGHT (UVR THERAPY)
Sunlight is the source of all types of light Ultraviolet light is part of the electromagnetic
energy used for therapeutic purpose. Thera- energy spectrum, which can be classified into
peutic lights are electromagnetic radiations three wavelength ranges:
 Therapeutic Light (Actinotherapy/Heliotherapy) 133

UV-C : 100 nm - 280 nm; Luminescence and Phosphorescence

UV-B : 280 nm - 315 nm;
Luminescence is the emission of light pro-
UV-A : 315 nm - 400 nm.
duced by means other than combustion such
as the luminous glow of a watch dial.
Points to Ponder
Ultraviolet radiation has particular physical
• Light is a form of electromagnetic energy characteristics, which affect such phenomena
that moves in measurable waves. as Luminescence and Phosphorescence and
• The human eye is capable of seeing only a can cause Fluorescence.
small segment of the spectrum known as
visible light; shorter and longer wave- Physiological Effects of UVR
lengths are not visible.
1. Antibiotic properties of UVR like inacti-
• Shorter length cosmic rays, gamma rays,
vation of toxins and destruction of bacteria
X-rays and UV light and the longer length
or virus are produced by UVR-C, having
infrared and radio waves are all invisible
wavelengths of 100 nm-280 nm. UVR-C is
to humans.
widely recognised for it’s bactericidal and
• UV radiations are between 180 nm and 400
antiviral properties, useful for sterilization of
nm wavelengths in the narrow region
infected wounds, medical supplies, surgical
between X-rays and the violet end of the
instruments, drinking water and processed
visible light spectrum.
food.
Biophysics of UVR UVR-C has been used as a disinfectant for
many years and is, in fact, still used for that
Fluorescence purpose. In the late 1900’s, Niels Ryberg
More than 3,000 natural and man-made Finsen used this bactericidal and antiviral
substances can transform invisible radiated property for a new application and started
UV into longer, visible wavelengths that using ultraviolet rays from external sources
appear in a variety of colours. These sub- for the treatment of diseases of the skin and
stances react to UV because they are com- mucus membrane, for which he was awarded
posed of easily excitable molecules. When UV a Nobel Prize in 1903. By the mid-1930’s
light strikes one of these molecules, photons treatment with ultraviolet was well accepted
cause each molecule to oscillate violently to for erysipelas and other skin infections, as
release longer, visible wavelengths that well as for mumps. Other researchers
appear to the human eye as a glow, in the Hancock and Knott (1942) have demonstrated
colour specific to activated substance. This the effectiveness of ultraviolet blood irradia-
phenomenon, called fluorescence is instan- tion (UVR) in treating both bacterial and viral
taneous and ceases the instant the UV light is infections, having demonstrated that ultra-
removed. Fluorescence lets users detect violet light could be used effectively in the
otherwise invisible traces that indicate various treatment of bloodstream infections. However
quality defects, diseases and contamination. with the debut of antibiotics, it’s ease of
134 Handbook of Practical Electrotherapy

treatment and its success in treating infec- water-cooled kromayer lamps and theractin
tions, it became the treatment of choice, and tubes.
UVR therapy fell by the wayside. • Air-cooled mercury vapour lamps consist of
2. Biotic properties of UVR are beneficial to a hot quartz tube, mounted on a movable
the living tissue. Out of the entire spectrum stand like an operation theatre light. It has
of UVR, UV-B (280 nm - 315 nm) and UV-A a hemispherical shutter to control the
(315 nm-400 nm) are known to have profound extent of exposure to the rays. The lamp
beneficial effects on the living tissues. produces bright bluish light, containing,
• Enhancement of the immune system’s predominantly UVB and UBA with a small
ability to fight infections. proportion of UVC in the wavelength
• Increase in oxygenation of the blood. range of 240 to 400 nm, along with signi-
• Activation of steroids. ficant amount of infrared and visible light.
• Increased cell permeability. Such lamps need to be warmed up for 5
• Release of vasoactive agents in the sub- minutes to ensure maximum output of
cutaneous capillary network resulting in UVR and are suitable for superficial
vasodilatation and reddening of the skin, wounds and pressure sores on the skin
known as erythema reaction. surface. Since significant heat is generated
• Increased desquamation i.e. peeling of the by this type of lamps. Hence the distance
skin. between the lamp and the skin surface
• Promote granulation should be 20 to 40 inches.
• Activation of cortisone-like molecules, • Water-cooled kromayer lamp contains a
called sterols, into vitamin D. cold quartz mercury vapour tube, moun-
ted in a hand held applicator unit, which
Sensitivity to UVR produces invisible UVC in the wavelength
Individuals vary in their sensitivities to range of 180 to 290 nm. This type of lamp
UVR. Persons with light skin shades are more needs no warm up time. The field covered
affected through tanning, though it is the dark by the lamp is just 5 sq cm and therefore,
skinned that run the risk of developing basal it’s suitable for small deeps sores or
cell carcinoma due to overexposure to UVR. sinuses. Since this type of lamp generates
Certain drugs such as tetracycline, sulpho- virtually no heat, it is applied in direct
namides, phenothiazine, quinine and gold contact with the skin surface.
may alter sensitivities of a person to UVR. • Theractin tubes consist of specially coated
Over-dosage with ultraviolet light may fluorescent tubes, arranged in a battery of
produce severe systemic reactions similar to 6 to 8 tubes fitted with in a semicircular
allergic reactions and lower the resistance to tunnel, which produces visible violet light,
bacterial infections. The level of exposure containing UVA in the wavelength of 400
required for an overdose is not approached nm. This type of lamp utilises biotic
in proper clinical practice. properties of UVR and is used for treat-
ment of neonatal jaundice, vitamin D
Instrumentation of UVR therapy deficiency and as a sunlamp for tanning
Therapeutic UVR is availed from three types the skin. Since no heat is produced and the
of sources, air-cooled mercury vapour lamps, desired effect is largely generalised, the
 Therapeutic Light (Actinotherapy/Heliotherapy) 135

distance of the tube form the skin should reaction increases in intensity for a few hours
be such that the field covers the entire and may be associated with superficial
body. oedema and peeling of the skin on strong
exposure. The reddening of the skin fades
Points to Ponder spontaneously after few hours or days.
• Therapeutic ultraviolet is produced by
Mechanism of Erythema Reaction
excitation of mercury atoms.
• The mercury vapour lamps may be of two It is dependent on histamine-mediated
types dilatation of the subcutaneous capillaries.
1. Hot quartz type (Alpine Sunlamp), Several anti-inflammatory agents like hista-
which produces heat and visible light mines; kinins are released from the mast cells
along with UVR- A, B and C. following exposure to UVR, which lead to
2. Cold quartz type (Kromayer Lamp), permanent dilatation of capillary network at
which produces mostly UVR-C. the site of the exposure, resulting in clearly
• Fluorescent tubes with phosphorescent demarcated area of uniform redness in the
coating, producing UVR-A along with skin. The reddening caused by exposure to
visible light. Arranged in Tunnels, which heat is often mottled and diffuse in nature.
is used for whole body exposure.
Dosimetry of UVR
Ultraviolet Applications The skin response to UVR depends on the
quantity of ultraviolet energy applied to per
Methods of UVR applications and its dose
square inch area of the skin, tone and the
depends upon:
sensitivity of the skin being treated. Since the
• The type of ultraviolet source being used.
sensitivity of UVR varies from person to
• The selection of the source depends upon
person, its optimum dosing parameters are
the type of the clinical problem being
determined on case-by-case basis, through
treated.
trial and error of application. This is known
• The most critical element in dosimetry of
UVR is the extent of erythema reaction as the test dose.
produced by UVR exposure on the skin.
Practical Points
Erythema Reaction • Take a 3” wide and 10” long strip of
flexible but opaque cardboard.
Definition • Cut three holes in the cardboard ½” × ¾”
Reddening of the skin, which appears a few of three different shapes, 3” apart.
hours after the exposure to UVR, is called • Fix the cardboard strip with adhesive tape,
erythema reaction. The intensity of the on the flexor surface of the forearm, lower
reaction is directly proportional to the dura- abdomen or chest of the patient, after
tion of exposure to UVR and varies according washing and drying the part. Ensure the
to types of skin tone and sensitivity of the test strip is flat on the body surface to
individual. After appearing, the erythema avoid shadows.
136 Handbook of Practical Electrotherapy

• Cover the part, along with the test strip hours, which subsides within 24 hours.
with a towel. The rest of the body of the Minimal erythemal doses are used for
patient should be draped with a sheet and generalised applications, useful for
the eyes protected with a UVR resistant vitamin D synthesis.
goggles. • First-degree erythema produces mild
• The Mercury vapour type UVR lamp reddening along with light peeling of the
should be placed 30”-36” away from and skin. It appears within 4 to 6 hours and
at right angles to the body surface, so that lasts for 48 hours. First-degree erythemal
the incident rays are perpendicular to the doses are used to treat superficial skin
skin. conditions such as Acne and sub acute
• The lamp should then be warmed up for psoriasis
5 to 10 min. • Second-degree erythema produces mar-
• Open the shutter of the lamp and expose ked reddening along with marked peeling,
the first cut out on the cardboard for 15 oedema and pigmentation of the skin
seconds, uncovering the second and the lasting for 72 hours. Second-degree ery-
third cut outs successively at intervals of themal doses are suitable for chronic
15 seconds. psoriasis, where peeling or exfoliation is
• With this procedure the first cut out is desired.
exposed for 45 seconds, the second for 30 • Third-degree erythema produces severe
seconds and the third for 15 seconds blistering, peeling and exudation along
respectively. with pain. It should be applied only on
• After the exposure is completed the shutter open sores or wounds, to destroy infective
of the lamp is close and the unit should be organism through UVC component and
switched off. promote the granulation through the UVB
• While using kromayer lamp preparation and A components.
of the patient and the test dose cutouts
remain the same. The distance of the lamp RED LIGHT THERAPY (INFRARED RAYS)
from the skin should be 1” or less. Three
Definition
cutouts are exposed one after another for
15, 30 and 45 seconds respectively. It is the therapeutic application of radiant
energy from a visible light source, commonly
Interpretation and Use of the Test Dose referred to as the red light, which emits both
• The patient is given a card with holes of visible light in the wavelength from 400 to 700
similar shapes as that on the test dose card. nm and invisible wavelengths from the
• The patent is asked to record the time at infrared portion of the electromagnetic
which reddening appears on the exposed spectrum, in the band width of 700-12000 nm.
spots on the skin and the time at which it
Biophysics
subsides, on the matching holes on the
card. Wavelength dependent photo biochemical
• Minimal erythemal dose, producing a faint reactions occur throughout nature and are
reddening on the Indian skin within 4 to 6 involved in such things as vision, photosyn-
 Therapeutic Light (Actinotherapy/Heliotherapy) 137

thesis, tanning and vitamin D metabolism. ceramic cylinder like in an electric room
Application of Red Light therapy has been heater and their working is similar in
shown in over 40 years of independent nature. The heating coil is mounted in the
research worldwide to deliver powerful front of a parabolic reflector, which directs
therapeutic benefits to living tissues and the radiations in a parallel beam towards
organisms. Such light contains both visible red the target area.
(600-700 nm) as well as invisible infrared rays • The lamp must be switched on at least
(700-12000 nm). 5 minutes before application of the
treatment, to warm up the heating
Types of Infrared Energy element and ensure maximum output
Infrared energy covers a bandwidth of of infrared energy.
• The area to be treated is exposed and
760-12000 nm with in the electromagnetic
inspected for any break in the skin or
spectrum.
any skin disease. The thermal sensation
• Near infrared rays or I.R.A have a wave-
of the skin must also be checked before
length range of 760 to 1500 nm and are
application of I.R. the rest of the body
emitted along with red visible light. This
is then draped with a sheet and the eyes
the commonest variety of infrared energy
must be protected with a pair of
used in physiotherapy. These rays pene-
sunglasses.
trate to the depth of 5 to 10 mm, reaching
• The lamp is then positioned 30-36”
the dermis and the subcutaneous tissue
away from skin. The position of the
and are emitted by the luminous infrared
reflector should be such that the radiant
lamps. Such lamps produce visible light,
energy falls perpendicular to the skin,
which is passed through a red colour filter
to ensure maximum absorption.
to eliminate undesirable wavelengths like
• The duration of exposure should be 20
the UVR from the visible light.
to 30 minutes in one sitting. During the
• Far infrared rays or I.R.B. and I.R.C. is
exposure the therapist must be avail-
emitted by any non-luminous heat source,
able within easy reach of the patient. If
like an electric heating coil or a hot water
the patient feels less or more heat the
bottle. These rays have a wavelength range
lamp may be moved closer or away
of 1500-12000 nm and penetrate to a depth
from the skin as the case may be. It is
of 2 mm and its effect is restricted only to
wise to remember that the feed back of
the superficial layers of the skin.
the patient is the only guide you have
to give appropriate dosing of I.R.
Methods of Application of Infrared Ray
Hence, ask the patient repeatedly
Two types of infrared sources are used in regarding the extent of heat being felt
physiotherapy practice. and be ready to adjust to the dose to
1. Non –luminous infrared lamps: These are suit the comfort level of the patient.
large lamps, similar to operation theatre • After completion of the treatment the
lights, mounted on a movable stand. They lamp may turned off or moved away
have a heating element mounted on a from the skin. The lamp may be kept
138 Handbook of Practical Electrotherapy

on if there are more patients to treat. nature. All biological systems have a unique
Inspect the skin that has been treated absorption spectrum, which determines what
for any undue reactions. Slight redden- wavelengths of radiation will be absorbed to
ing of the skin over the exposed area is produce a given therapeutic effect. Lasers are
to be expected and this should be focused beam single-wavelength (monochro-
explained to the patient. matic) light that can be intense enough to
• In case of irritation or severe reddening burn/cut tissue or mild enough to only have
of the skin calamine lotion (lacto cala- photobilogical effects on the living tissues.1
mine) may be applied over exposed Laser devices emit an intense, coherent and
skin. It should be realised that fair skin highly directional beam of “light” which may
reddens more readily as compared to be infrared, visible or ultraviolet, depending on
dark skin. the type of the diode being used.
2. Luminous infrared lamps: These are devices The peak power output of lasers is mea-
consisting of an incandescent bulb of 150 sured in watts. The primary reaction of laser
watts mounted on parabolic reflector, on the living tissue is thermal i.e. production
having portable or stand mounted set-up.
of heat which. Such heat is due to the highly
The incandescent lamp has a red filter
intense nature of the beam and its ability to
placed in front or painted on to the
be focussed over small areas. The heat is suffi-
faceplate of the bulb. This filter helps to
cient to coagulate or ablate tissue by evapo-
remove the UVR associated with the
ration. However, even with low power
visible light produced by the incandescent
application of laser, significant benefits were
bulb. These types of lamps are preferred
observed in diseased tissue, without any
by most clinics and for home use because:
• No warm-up time needed. The lamp destruction of the cells. This led to the use and
gives maximum output as soon as it is subsequent popularity of low power laser in
turned on. physiotherapy and very low power laser in
• It has deeper penetration and therefore dermatology. Effects of such laser exposure
greater effect on body tissues. are mainly photo biological in nature. The
• Face and the eyes need to be protected peak power output of laser is measured in
strictly due to the presence of visible watts used frequently for endoscopic surgery
and UVR in the luminous I.R. output. for endometriosis, vascular surgery, etc.2
• The distance from the lamp to the skin Other reactions of laser exposure are used
should be 18-24” and the duration of are photo biological in nature. In physio-
exposure should be 15 to 20 minutes. therapy low powered lasers as used and in
• Procedure of application, patient pre- ophthalmic treatments such as capsulotomy
paration and precautions observed are photo acoustic effect is used.3
similar to non-luminous IR applica-
Points to Ponder
tions.
• LASER stands for “light amplification by
THERAPEUTIC LASERS stimulated emission of radiation”.
Lasers are devices for producing light at • Laser consists of a large number of identi-
specific wavelengths that is therapeutic in cal photons emitted from an energised
 Therapeutic Light (Actinotherapy/Heliotherapy) 139

source called a diode on application of will protect the eye. Positioning lasers used
electrical charge. for aligning patients for radiotherapy, X-rays
• Laser radiations have the same wave- and scans are usually Class 2
length i.e. are mono chromatic in nature. Class 3a - Similar to Class 2, except that if the
• Laser radiations are coherent in phase and beam is focussed onto the eye, e.g. through
direction, i.e. has temporal and spatial magnifying glasses, beam could be hazar-
coherence. dous.
• Laser emitted from a source is collimated Class 3b – Potentially hazardous to the eyes
in nature, i.e. parallel to each other. because either the blink reflex is not fast
• Laser behaves like light i.e. they can be enough to prevent damage or the beam is
reflected, refracted and absorbed. invisible and therefore the blink reflex cannot
work. Lasers used in physiotherapy produce
Different Types of Lasers invisible infrared beams (Galium-Alumi-
Employed for Clinical Use (Table 13.1) nium-Arsenide Diode) at class 3B.These
i. Candela pumped dye laser: equipments also incorporate a visible orange
Dermatology (Helium-Neon diode) as an aiming laser beam
ii. Neodymium: YAG laser: at lower power, which should also be regar-
Surgery ded as hazardous. In scanning laser, the power
iii. CO2 Laser: density is considerably reduced by the
Obstetrics and Gynaecology cylindrical lens, which spreads the beam from
iv. Argon; iris diode lasers: a spot to a line.
Ophthalmology Class 4 – High power devices capable of
v. He-Ne; infrared diode lasers: causing immediate injury to the skin, eye or
Physiotherapy living tissue - even diffuse reflections may be
hazardous. Most surgical lasers are in Class
Hazards of Laser Therapy 4. Damage from Class 4 lasers can occur in a
fraction of a second, far faster than the eye
The principal hazard due to laser is damage
can blink to shut out the beam. The hazard
to the eye. Laser radiations in the visible and
can arise from direct exposure to the laser
near infrared wavelengths can penetrate the
beam or accidental reflections of the beam
eye and damage the retina permanently,
from shiny objects. It must be stressed that eye
where as radiation in the ultraviolet and far
damage is the most likely and immediate
infrared wavelengths can cause damage only
injury - thus the operating rules must be
to the surface of the eyes. Lasers are divided
understood and adhered to by all staff
into five hazard classes, depending on the
involved. The likelihood of an accident is very
output and the risk of damage from accidental
small, but the consequences are often serious.4
exposure.The hazard classes of laser used in
Other potential hazards are fire. Lasers can
clinical practice are:
ignite flammable materials. Laser may cause
Class 1 - Intrinsically safe explosion of anaesthetic gases or ignite
Class 2 – Low power devices emitting visible inflammable substances like surgical ether
light - not completely safe, but the blink reflex causing skin burns.
 Table 13.1: Different types of lasers employed for clinical use
Type of Excitable Method of Frequency of Class of laser Colour of Adverse effects Clinical use
clinical laser compound excitation emission and power emitted emission

Ruby laser Synthetic ruby Helical xenon 694.3 nm Class 2 low Visible red light None Dermatology
rod made of tube wound power laser
aluminium round the ruby < 1mW
oxide rod emitting
intense flash of
140 Handbook of Practical Electrotherapy

light

Helium – Sealed glass Helical xenon 632.8 nm Class 2 low Visible red light None, if not Marker for
Neon laser tube containing tube wound power laser focused directly application of
helium and neon round the >1mW on the eye invisible lasers
gases ruby rod emit-
ting intense
flash of light

Infrared diode Specialized Application of 650-1300 nm Class. 3a low Visible red light Direct exposure Bedsores, indolent
lasers light emitting electrical pulse continuous medium >5mW with some to the eye wounds, musculo-
diodes made to the diode 860-904 nm Class3b medium infrared harmful skeletal disorders,
of gallium pulsed mode power >500mW Invisible Infrared Reflected pain relief, etc.
aluminium exposure is
arsenide dangerous to
the eyes
 Therapeutic Light (Actinotherapy/Heliotherapy) 141

Procedures and Equipment extinguisher. The supervisor, in a secure place

when not in use, shall keep the master key
The Nominal Ocular Hazard Area (NOHA) for each laser and an authorised person
is the region around a laser therapy unit, should only energise the equipment fre-
where eye protection is essential. For thera- quently for endoscopic surgery for endo-
peutic laser this is the entire room, in which metriosis, vascular surgery, etc. All lasers must
the laser is being used, but it may be less for be checked routinely for proper output and
specific lasers, e.g. NOHA is within one metre performance prior to each procedure. Faults
of any ophthalmic laser. It is important to should be notified immediately to the Bio-
avoid any unexpected entry into a laser area medical Engineer in charge.
when the equipment is in use. A laser hazard
sign must be displayed at eye level at all REFERENCES
entrances to the room. The hazard sign must 1. Lasers and Wound Healing, Albert J. Nemeth,
MD; and Dermatology Centre, Clearwater FL,
indicate the classification and type of laser
Dermatologic Clinics, Vol. 11 #4, 1993.
being used. Ensure that all personnel working 2. Wound management with Infrared Cold Laser
with the laser are adequately instructed on eye Treatment, P Gogia; B Hurt and T Zim; AMI-
safety measures. Ensure that adequate supply Park Plaza Hospital, Houston TX, Physical
of protective eyewear for the particular type Therapy, Vol. 68, No. 8, August 1988.
3. Effects of Low-Level Lasers on the Healing of
of laser is available. Appropriate eye wear
Full-Thickness Skin Defects, J Surinchak. MA;
specific to the type of laser being used must M Alago, BS, R Bellamy, MD; B Stuck, MS and
be worn by all staff present during the M Belkin, MD; Lettennan Army Institute of
treatment procedure, and spare eye wear Research. Presido of San Francisco, CA; Lasers
must be available for staff wanting to enter in Surgery and Medicine, 1983;2:267-74.
4. Effect of Laser Rays on Wound Healing, E
the area. Staff working with lasers, which have Mester, MD; T Spiry, MD; B Szende. MD and J
the ability to ignite flammable materials, must Tola; Semmelweis Medical Univ. Budapest, the
be aware of the location of a nearby fire American Journal of Surgery 1971;122.
142 Handbook of Practical Electrotherapy

14
Frequently Asked Questions in
Practical: Viva Examination
SECTION 1: DEEP THERMOTHERAPY also are much more expensive than solid-
state units.
Q 1. What do you understand by SWD? • SWD equipments with solid-state circuit
A. It is a method of producing deep heat in have an output of 100 to 250 watts over
the body tissues using high frequency current short periods and are prone to overheating
at the frequency of 27.12 MHz and wave- on continuous use. These units have light-
length of 11 meters. weight, rugged-construction and are
Q 2. What are the effects and uses of SWD? therefore, suitable for portable use.
A. Primary effect of SWD is to generate heat Q. 4. What are the important features of a
in body tissues by subjecting it to an oscilla- modern SWD machine?
ting electrical field. Results of such heating are A. Modern SWD machines have individual
increased blood circulation, metabolic rate, controls for input voltage, output intensity,
protein synthesis and drainage of cellular tuning and autocut timers. Many models have
waste. These effects are used for relief of pain, auto-tuning facility for quick and accurate
spasm of muscle, stiffness of joints, resolution tuning of the machine circuits with the patient
of inflammation and tissue healing. circuit. Most modern equipments have
Q 3. What are the types of SWD machines? individual output sockets for cable and
A. SWD machines are available with valves condenser electrodes. The equipments should
or solid-state circuit. also have provision for using cable, disc and
• The valve sets have the advantage of pad electrodes, along with flexible disc
giving consistent outputs in the range of electrode mounting arms as standard accesso-
400 to 500 watts over long periods of conti- ries.
nuous operation without overheating and Q. 5. What type of input current is used in
therefore, suitable for hospital or clinic use. SWD? What is the output current frequency
The disadvantages of valve sets are that and wavelength?
these units are larger, heavier, have delicate A. AC current from a domestic power outlet,
RT valves that need careful handling and with a voltage range of 220 to 240 volts is used
 Frequently Asked Questions in Practical: Viva Examination 143

to operate SWD machines. The output current Q. 11. How much thickness is appropriate
is high frequency current with a frequency of for spacers?
27.12 and wavelength of 11 meters. A. 2 to 4 cm.
Q. 6. What are the common methods of Q. 12. What should be the appropriate
application of SWD? distance between two condenser plate
A. Condenser field and cable method. electrodes?
A. The minimum distance between two
Q. 7. What is condenser field method of
condenser plates should be greater than the
SWD?
sum total of the thickness of the spacers being
A. Body tissue is interposed, as a dielectric
used.
medium, between two condenser electrodes,
metal disks or plates, enclosed in non- Q. 13. What is the method of heat production
conducting covers like plastic or rubber. in cable SWD?
Q. 8. Which tissue is heated most in con- A. Heat is produced by oscillation of ionic
denser field method? particles present in the tissue due to the effect
A. Tissues with minimum water or electrolyte of eddy current generated by electromagnetic
content, which offers maximum resistance to induction. Cable method is also called
oscillating high frequency current, like the inductothermy.
subcutaneous fat or skin, are heated most with Q. 14. Which tissues are best heated by cable
condenser field application of SWD. method of SWD?
Q. 9. What are different techniques of A. Tissues with high ionic content like blood
condenser plate electrode placement used in or muscles are best heated.
SWD? Q. 15. What type of cable is used in cable
A. Coplaner, contraplaner and cross-fire method of SWD?
placement. A. Coaxial cable with a flexible conducting
Q. 10. What are spacers? Name a few spa- core coated with a layer of heat resistant
cers. rubber.
A. Spacers are layers of insulating material
Q. 16. What is the optimum length of the
containing large air-spaces, which are inter-
cable used in SWD? Why?
posed between the condenser electrodes and
A. Since the wavelength of SWD is 11 meters
the skin surface. The spacers can be perforated
and resonance of such waves will be possible
felt pads, Turkish towel or air-space. The
in either 1/2 or 1/4 of the wavelength, the
spacers increase the distance of the electrodes
optimum length of the inductothermy cable
from the skin, eliminating irregularities of the
should be 2.25 meters or multiples thereof.
body surface, for even distribution of the lines
of forces. Concentration of the lines of forces Q. 17. When is pulsed SWD recommended?
on a specific spot may cause overheating and A. Pulsed SWD is recommended when heat
burn. component of the SWD is not desired but the
144 Handbook of Practical Electrotherapy

electromagnetic field is deemed to be bene- mission of energy from the transducer to the
ficial for any condition like broken bones, body. This is essential, since air is a reflector
wounds and acute inflammation. of ultrasound energy.
Q. 18. How is the dose of SWD calculated? Q. 23. What effects does ultrasound energy
A. The dose of SWD is delivered based on the produce in the body tissue?
feedback of the patient. Hence, it is man- A. Mechanical effect, thermal effect and micro
datory that the patient must have intact streaming effect.
thermal sensation over the area being treated. Q. 24. What are the benefits of ultrasound
The patient should be able to guide the application?
therapist on the extent of heat being felt, based A. a. The mechanical effect causes micro
on which the output of the equipment is massage at the tissue level. This helps
adjusted. break down adhesions, soften scar
tissue and release soft tissue contrac-
SECTION 2: ULTRASONIC THERAPY tures.
Q. 19. What do you understand by therapeu- b. The thermal effect raises tissue tempe-
tic ultrasound? rature that may help in resolution of
A. Therapeutic ultrasound is sound energy inflammation and reduce pain.
beyond the range of human hearing at the c. The micro-streaming effect promotes
frequency range of 0.8 to 3.8 MHz, applied to protein synthesis at the cellular level
the body tissue through a transducer. that is useful in the process of repair.

Q. 20. What are the essential components of Q. 25. What are the different modes of US
ultrasound therapy machine? application? How do they differ in charac-
A. Therapeutic ultrasound equipment consis- ter?
ts of a high frequency current generator, a A. a. Therapeutic ultrasound can be applied
transducer with a quartz piezoelectric crystal to the body in continuous or pulsed
and a coaxial cable that transmits the high fre- mode.
quency current from the generator to the b. In continuous mode the output of U.S.
crystal. energy is uninterrupted and has a large
thermal component.
Q. 21. What are coupling mediums? c. If the continuous flow of ultrasound is
A. Coupling mediums are liquid or gel with interrupted at specific intervals, the
minimum acoustic impedance that transmits thermal component is reduced signifi-
ultrasound energy from the transducer to the cantly, though the other effects like
skin, e.g. degassed water, glycerine, aqueous mechanical and micro streaming
gel, etc. remains intact. This is known as pulsed
Q. 22. What is the role of coupling medium U.S.
in application of US therapy? Q. 26. What is the relevance of mark-space
A. Coupling mediums eliminate air-space ratio?
between the faceplate of the ultrasound A. Mark-space ratio is relevant to pulsed U.S.
transducer and the skin and allow trans- It signifies the ratio between the duration in
 Frequently Asked Questions in Practical: Viva Examination 145

milliseconds, of energy flow with the interval reflection and refraction is called attenuation.
between successive pulses of energy. Usual The extent of energy loss due to absorption is
mark space ratios used in therapeutic U.S. are 60%, due to refraction and reflection 25%.
1:4, 1:8 or 1:16, the higher values indicating
Q. 31. What are the principal therapeutic
lesser thermal content.
uses of ultrasonic therapy?
Q. 27. What are the dosing parameters of US A. Healing of acute soft tissue injury, relief of
therapy? neurogenic and somatogenic pain, increase
A. • Mode of Ultrasonic- pulsed mode gives pliability of soft tissue contractures and scars
less power than continuous mode and healing of chronic ulcers.
• Frequency of Ultrasonic- Lower the fre-
Q. 32. What are the different methods of
quency of the US greater the penetration.
application of therapeutic ultrasound?
• Intensity of US energy- measured as W/
A. Therapeutic ultrasonic can be applied:
cm2
• Duration of exposure. i. By direct contact method using coupling
• Frequency of repetition of treatment- in gel
acute, superficial lesions, low intensity at ii. In a bath of de-gassed water
high frequency, in a pulsed mode for a iii. Through a water bag
short duration (<3 min) may be repeated iv. Through a solid sheet of coupling gel.
twice a day for very short duration. For Q. 33. What are absolute contraindications
deep, chronic lesions- high intensity at low for application of ultrasonic therapy?
frequency, in a continuous mode for a long A. Absolute contraindications for application
duration (>5 min) may be given on alter- of ultrasonic therapy are:
nate days. • Tumours in precancerous stage or malig-
Q. 28. What do you understand by half value nant.
distance of US? • Pregnant uterus
A. The distance at which, from the point of • Testes and ovary
contact of the transducer on the skin, the value • Acute infective focus like boils and
of the sound energy reduces by half is known carbuncles
as the half value distance. • Tissues that bleeds easily
• Deep vein thrombosis
Q. 29. What are the factors that determine
• Over the eyes
the absorption of US energy?
A. Absorption of the US energy depends on Q. 34. What is phonophoresis?
the nature of protein and water content of the A. Introduction of medicinal substances into
target tissue, frequency and the wavelength and through the skin using ultrasound energy.
of the ultrasonic energy being used. Q. 35. What type of ultrasound energy is
Q. 30. What do you understand by attenua- suitable for phonophoresis?
tion of ultrasound? A. Low intensity, low frequency ultrasound,
A. The loss of energy from the ultrasound applied over longer durations (>8 min) is
beam in the tissues due to absorption, most suited for phonophoresis.
146 Handbook of Practical Electrotherapy

SECTION 3: THERAPEUTIC • Treat infections by copper sulphate ionto-

STIMULATING CURRENTS phoresis.
• Treat inflammation and pain by Methyl
Q. 36. What are the characteristics of thera-
salicilate and iodine iontophoresis.
peutic direct current?
A. It is a unidirectional flow of electrons Q. 40. What are the risk factors of iontopho-
through the tissues that may be continuous resis?
(Galvanic) or interrupted (I.G.) at preset pulse A. Potential risk of:
duration, frequency and pulses intervals. • Chemical burns.
• Electric shock.
Q. 37. What are the biophysical properties of
• Skin irritation and allergic dermatitis.
continuous DC?
• Anaphylactic shock due to drug allergy.
A. Continuous DC sets up convection current
in the tissues, causes electrolysis under the Q. 41. What do you understand by an elec-
electrodes, which can produce transcutaneous tric pulse?
penetration of therapeutically valuable ions A. An electrical pulse is an isolated electrical
into and through the skin to the subcutaneous incident, defined by a specific duration in
circulation, by the force of ionic dissociation. millisecond, intensity in milliamperes/volts
and rate of repetition/frequency in Hz.
Q. 38. What are the physiological effects of
therapeutic DC? Q. 42. What are the biophysical charac-
A. Physiological effects of DC are: teristics of a stimulating electrical pulse?
• Stimulation of sensory nerve ending in the A. The bio-physical properties of any
skin creating a tingling sensation. stimulating electrical pulse depends on
• Reflex vasodilatation of peripheral capi- • Phase or direction of current flow- Mono-
llary network resulting in reddening of the phasic or Biphasic.
skin. • Waveform or the shape of the pulse on a
• Increase sensitivity of peripheral nerve cathode ray tube.
ending. • Frequency or rate of repetition in PPS or
• Relief of pain by blocking of pain trans- Hz.
mission. • Ramping or progressive increase of inten-
• Accelerate of tissue healing. sity in each successive pulse, arriving in a
• Introduction of drugs through the skin- train of impulses.
Iontophoresis. • Rate of rise and fall from zero to peak
intensity.
Q. 39. What are uses of Iontophoresis?
A. Iontophoresis can be used to introduce Q. 43. How do you classify therapeutic
selected drugs through transcutaneous rout currents on the basis of pulse frequency?
for: A. Therapeutic currents can be classified on
• Local anaesthesia by lignocaine/xylocaine the basis of pulse frequency as:
iontophoresis. • Low frequency- 1 - 1000 Hz.
• Treat hyperhydrosis by water iontopho- • Medium frequency- 1000-10,000 Hz
resis. • High frequency – 10, 000- 100, 000, 000 Hz.
 Frequently Asked Questions in Practical: Viva Examination 147

Q. 44. How do you classify low frequency Q. 47. What is the expected response to a
stimulating currents? series of stimulating current impulses
A. Low frequency stimulating currents are applied to the skin?
classified on the basis of pulse duration as: A. The reaction to such stimulation would be:
• Long duration currents- those with pulse • Stimulation of sensory nerve ending
causing a tingling sensation at liminal
duration > 1 m.sec, includes all types of
intensity and pain at higher intensity.
muscle stimulating currents, such as
• Stimulation of motor nerves causing titanic
rectangular, square, trapezoidal, triangular
muscle contraction.
and trapezoidal pulses.
• Short duration currents- those with pulse Q. 48. What are the expected responses to
duration < 1 m.sec, , includes all types of low frequency stimulation at commonly
nerve stimulating currents, such as faradic used rates of repetitions?
current, TENS, HVPGS, etc. A. Responses to low frequency stimulation at
different rates of repetitions commonly used
Q. 45. What is the mechanism of action of are:
low frequency stimulating currents? • 1Hz- Twitch muscle contraction along with
A. A single electrical impulse with appro- sharp shock.
priate pulse duration, strength and shape • 10 Hz- Fast twitches of muscles along with
triggers an action potential in a nerve. This tapping sensation.
action potential spreads through out the nerve • 30 Hz – Rapid twitch contraction of
membrane to trigger momentary depolari- muscles along with tingling sensation.
sation of the nerve. In a motor nerve, this • 100 Hz- Tetanic contractions of muscles
depolarisation spreads to the muscle, causing along with strong tingling sensation.
a muscle twitch and in a sensory nerve it • > 100 Hz- Used as TENS for pain modula-
creates a sensory impulse that is carried to the tion.
sensory receptors in the brain as a tingeing
Q. 49. What are the therapeutic effects and
sensation.
uses of low frequency stimulation?
Q. 46. What are the requisite parameters to A. Therapeutic low frequency stimulation are
produce a response with a stimulating used for:
current? • Strengthening of healthy muscles, even
A. To produce a perceptible response in a when immobilised.
nerve or muscle, the stimulating current must • Preventing atrophy in denervated or
have: immobilised muscles and retaining func-
• Sufficient intensity, which must be equal tional capability of muscles at risk of
to the rheobase value for long duration disuse, through enhanced vascular turn-
pulses and more than the rheobase value over and metabolic activity. Other tissues
for short duration pulses. in the vicinity are also benefited by
• Adequate rate of rise and fall from zero to increased drainage and supply of body
peak intensity and back. fluids.
148 Handbook of Practical Electrotherapy

• Building up or retaining voluntary muscle Q. 51. What are the primary considerations
control. for application of therapeutic electricity?
• Maintaining or increasing muscle joint A. Following issues should be addressed
range of motion. satisfactorily for selection of any electro-
• As a functional aid, promoting voluntary therapy modality:
muscle action, control hyper or hypo tonus • The effect desired i.e. pain relief, tissue
and splint the limbs in functional position healing or restoration of motor function.
during activities of daily living.
Modalities must be selected on the basis
Q. 50. What are the mechanisms of action of of the effect desired.
electric charge, in producing therapeutic • The extent of safety involved. All moda-
effects in the body? lities have potential hazards.
A. Therapeutic effects produced by appli- • The cost involved. The selection modality
cation of electrical charge to the body are due should be such that it achieves results in
to: the shortest possible time.
• Direct current causes chemical changes,
used in phonophoresis. Q. 52. What are the primary mechanisms of
• Low frequency currents cause stimulation pain modulation by TENS?
of excitable tissues A. Pain modulation by TENS is achieved by:
• High frequency currents cause heating • Activation of the spinal gate through
• Low intensity D.C. and different types of sensory nerve stimulation
pulsed currents can stimulate repair and • Release of indigenous opiates like B-
growth in tissues. endorphins, through stimulation of the
• Placebo effect nociceptors.
 Index
A E High frequency currents 21
production of 86
Absolute refractory phase 6 Electrical energy 11 subtypes of 21
Actinotherapy 131 Electrical field 2 High voltage pulsed galvanic
physics of 132 behaviour of 2 stimulation 57
Action potential 5 Electrical impulses, types of 16 application of 58
propagation of 6,7 Electrical safety 10 effects and uses of 58
Electrical stimulation 20,24, 36 instrumentation of 58
B Electrical stimulators 30-36 parameters of current 57
electrical muscle 30 Hyperpolarisation, phase of 6
Bioelectrical drama, significance
functional electrical 30
of 8
high voltage galvanic 30
Bioelectricity 2 I
interferential therapy unit 30
C neuromuscular stimulator 30 IFT therapy 67-69
TENS 30 advanced interferential
Combination therapy 113-115 Electrical stimulus 16-19 equipment 68
biophysics of 113 nature of 16 clinical application of 68
contraindications for 115 strength duration curve 18 clover leaf pattern in 71
important considerations 113 Electrophysiology 2 electrodes for application
technique of application of 114 Electrotherapy unit, equipment of 72
treatment protocol of 115 safety in 11 instrumentation of 68
Conduction 6 Electrotherapy, safe application isoplaner vector field
antidromic 6 procedure of 12 application 71
local circuit 7 Endorphin release theory, TENS treatment parameters to 69
orthodromic 6 50 treatment techniques to 70
Coupling mediums 100 Inverse square law, radiation 83
Cryotherapy 119-129 Iontophoresis 61-64
F
application of therapeutic application in 63
cold 129 Fluorescence, phenominon 133 hyperhydrosis 63
biophysics of 119 Functional electrical stimulation local anaesthesia 63
cryo-kinetics 125 58-61 local inflammation 63
exercise-specific guidelines 126 application in 59-61 biophysics of 62
physiological effects of 120 foot drop 61 contraindications of 64
techniques of 121 hemiplegic’s shoulder 59 dosimetry of 62
commercial cold packs 122 idiopathic scoliosis 60 electrodes for 63
contrast bath 123 effects and uses of 58 indications for 62
coolant spray 123 instrumentation of 59 ionising agents 63
ice massage 122 parameters of current 58 ions commonly used in 64
ice packs 121 technique of application 64
ice towels 122 G
techniques of local cooling 128 L
Gate control theory, TENS 50
Lambert’s cosine law, radiation 83
D Low frequency currents 18
H
Deep thermotherapy 142 production of 21
Depolarisation 6 Heliotherapy 130 subtypes of 19
150 Handbook of Practical Electrotherapy

M in foot drop/flail foot 43 wave patterns of 22

in wryneck 39 pure faradic current 20
Medium frequency current 20, therapeutic model 30 transcutaneous electrical
65-73 vaginal electrode 35 nerve stimulation 20
burst mode TENS 20 Motor point 23 Superficial heat therapy 76-84
conventional TENS 20 Motor unit 17 comparative profile of 84
current forms used in 21 contraindications for 78
interferential current 20, 65, 66 indications for 77
N
clinical applications of 73 physiological effect of 77
clover leaf pattern 71 Nernst potential 5 preparation of patient 78
physiological effects of 67 Nerve conduction velocity 9 transmission of 76
therapeutic effects of 67 Neuromuscular electrical types of 79
two pole medium stimulation 24 Hubbard’s tank 81
frequency current 72 hydrotherapy 79
types of 71 R moist hot packs—hydro-
medium frequency surge collator 79
current 65,66 Red light therapy 136 paraffin wax bath 82
Russian current 65 biophysics of 136 radiant heat–infrared rays
selectively TENS 20 methods of application of 137 83
types of 65 types of 137 steam bath or sauna 82
Microwave diathermy 92-96 Relative refraction, phase of 6 whirlpool bath 80
biophysics of 92 Resting membrane potential 3,4
contraindications for 96
indications for 96 S T
technique of application of 96
Modern low frequency electrical Short-wave diathermy 85-92 Therapeutic current 18
stimulators 30-47 application of treatment with types of 18
clinical applications of 37 91 Therapeutic heat 76
diagnostic electrical biophysics of 85,87 Therapeutic lasers 138
stimulator 31 cable method 91 different types of 139
diagnostic stimulator 30 condenser field method 90 hazards of 139
electrode placement 35 contraindications of 89 procedures and equipment of
machine preparations 32 disc electrodes used in 90 141
patient preparations 33 electrode placement 90 Therapeutic light 132
rectal electrode 35 indications for 89 types of 132
selection and preparation, method of application 85, 86, Therapeutic stimulating currents
electrodes 33 89 146
special type of electrodes 35 physiological effects of 88 Therapeutic ultrasound 99-111
specialised techniques used in technique, specific disease biophysics of 99
44 conditions 92 contraindications for 103
faradic footbath 44 therapeutic benefits of 88 digital ultrasonic machine 104
faradism under pressure 46 Static electricity 2 dosimetry of 116
faradism under tension 47 Stimulating current 19, 21 indications for 102
techniques in, clinical faradic type of current 20 phonophoresis 110
conditions 37 interrupted galvanic current 19 phonophoretic agents 111
in Bell’s palsy 38 iontophoresis 20 physiological effects of 101
in crutch palsy 41 low frequency current forms 19 technique of application of 104
in Erb’s/klumpke’s palsy modulation of 22 direct contact method 105
41 production of low frequency 21 water bag method 106
in fibromyositis of production using multi- water bath method 109
trapezius muscle 40 vibrator circuit 22 ultrasonic transducers 99
 Index 151

Transcutaneous electrical nerve U medial collateral ligament,

stimulation 26,50-56 knee 110
applications in common Ultrasonic therapy, application over the medial epicondyle 106
disorders 56 of 106-112, 144 palmar fascia for Dupuytren’s
contraindications for 53 calcaneal spur 112 contracture 107
current forms used in 20 carpal tunnel ventral aspect sternocostal joint for costo-
different types of 51 108 chondritis 107
electrode placement in 53 clavicular fossa for brachial subacromial bursa 107
equipment and the nature of neuralgia 110 supraspinatus tendon 107
current 50 extensor policis brevis 108 temporomandibular joint 107
general rules, placements of extensor policis longus 108 tendon of abductor policis
electrodes for 54 fibromyositic nodule in longus 108
rhomboids muscle 111 Ultrasound energy, wave
mechanism of action of 27
hydrocortisone phonophore- patterns of 98
modulation of 52
sis therapy, ankle 112 Ultraviolet radiation therapy
parameters for optimal
iodex phonophoresis therapy, 132-135
stimulation of 53
popliteal bursa 112 biophysics of 133
physiological effect of 50
lateral collateral ligament, dosimetry of UVR 135
precautions for home
ankle 111 erythema reaction 135
prescription 53
lateral epicondyle 108 instrumentation of 134
waveforms of 52
lidocaine phonophoresis sensitivity to 134
when not to use 28
therapy 112 ultraviolet, applications of 135