● Melzack and Wall

○ In 1960’s the use of

electrical currents for
controlling pain is derived
Introduction & History from the gate control theory
of pain perception
Electrical Currents ■ Electrical current
● Flow of charged particles either can produced the
electrons or ions light touch like
● Galvani sensation
○ First recorded producing
muscle contractions by
touching metal to a frog’s Gate Control Theory
muscle “animal electricity” ● Causes increase activity of A-beta
○ Later on termed as : presynaptic inhibition of T cells
“Galvanic Current” after ● Thus, closes the spinal gate to the
volta constructed the cerebral cortex and decrease pain
precursor to the battery sensation
○ Direct current

● Duchenne
○ Mapped out locations on
the skin where electrical
stimulation most effectively
caused specific muscles to
contract termed as motor
points
■ In motor points we
elicit muscle
contraction with
minimal electricity
needed
Clinical Applications of Electrical
● Faraday Stimulation
○ Discovered that ● Production of muscle contractions
bidirectional electrical ● Control of acute, chronic and
currents could be induced postoperative pain
by a moving magnet ● Promotion of tissue healing
termed as “Faradic ● Muscle strengthening and
current”, that can also reeducation : reduce muscle
produced mm cxn spasms
○ Alternating current ○ It has to be active assisted
● Enhanced transdermal drug
● Lapicque delivery / iontophoresis
○ In 1905, he introduced the
concept of the strength
duration curve
Electrical Parameters
● Waveforms
● Time dependent parameters
● Amplitude
● Frequency
● Ramp up / down

● Waveforms
○ Direct current
■ Unidirectional flow
of charged particles
■ Only 1 charge
■ Commonly used for
iontophoresis and
stimulating
denervated muscles
■ High cases of burns

● Medium Frequency currents

○ Alternating current
○ Interferential Current (IFC)
■ Continuous
■ For pain control
bidirectional flow
■ 1,000-10,000 Hz
■ Used for pain
■ Interference of 2
control and muscle
med. Freq currents
contraction
of slightly different
frequencies
○ Pulsed current
■ Electrodes are
■ Interrupted flow;
configured on the
current flow in a
skin so that the two
series of pulsed
ACs intersect
separated by
■ More comfortable
periods of no
than other
current flows
waveforms
■ Have on and off
● Esp the
time
target area
■ Used for pain
is quite large
control, tissue
– back
healing, and muscle
■ Stimulate a larger
contraction
area than other
■ Most commonly
waveforms
used
■ Carrier frequency
■ Safest – have on
● 5,100 Hz /
and off time – lesser
5,000 Hz
risk for burns
● Kung ano
yung
frequency ng
2 electrodes
 ■ Beat frequency intended for
● Difference of quadriceps muscle
the 1st and strengthening
2nd ■ Developed by the
electrode russians to
● Because strengthen
they meet, quadriceps
pagdating sa ■ Uses a medium
middle frequency AC with a
na-cancel frequency of 2500
out yung Hz delivered in 10
frequency ms long bursts
nila ■ There are 50 bursts
per second with a
10 ms interburst
interval between
bursts
■ A.k.a medium
frequency burst AC
(MFburst AC)

○ Pulsed Current
■ Interrupted flow of
○ Premodulated Current charged particles
■ An alternating where the current
current with a flows in a series of
medium frequency pulses separated by
(1,000 to 10,000 periods where no
Hz) and sequentially current flows
increasing and ■ Has monophasic /
decreasing current biphasic
amplitude
■ Produced with a ➢ Monophasic
single circuit and ○ Flows only 1
only 2 electrodes direction during a
■ This current has the pulse
same waveform as ○ Commonly used to
an IFC promote tissue
■ For pain control healing and for
acute edema
*IFC & Premodulated current can only be management
performed in a specific machine ○ Most commonly
encountered
○ Russian Protocol monophasic current
■ Electrical : high volt pulsed
stimulation with a current (HVPC)
waveform with a.k.a pulsed
specific parameters galvanic current =
 this waveform is ○ One study subjects
made up of pulses found asymmetrical
composed of a pair biphasic waveforms
of short, : more comfortable
exponentially when used to
decaying phases, produce
both in the same contractions of
direction smaller muscle
■ As it goes groups, symmetrical
off, the biphasic waveforms:
intensity comfortable when
lowers down used to produce
it doesn’t go contractions of
straightly to larger muscle
0 groups, such as the
○ Have on and off but quadriceps
the polarity of ○ Asymmetrical
electricity is only 1 biphasic and
symmetrical
➢ Biphasic biphasic were
○ Flows back and equally effective for
forth during a pulse controlling pain in
/ faradic current an animal model
○ May be
symmetrical or
asymmetrical, and if
asymmetrical, may
be balanced or
unbalanced
○ Symmetrical or a
balanced
asymmetrical
biphasic pulsed
current, the charge
of the phases are
equal in amount and
opposite in polarity
resulting in a net
charge of 0
○ Unbalanced
asymmetrical
biphasic current, the
charge of the
phases are not
equal, and there is a
net charge
**red color : on time ● Frequency
**black color : off time ○ Number of cycles or pulses
per second and is
**the shape of your waveform depends on measured in Hertz (Hz) or
how you control the parameters pulses per second (pps).
Different frequencies are
● Time Dependent Parameters chosen depending on the
○ Pulse Duration goal of the treatment
■ How long each ○ When we adjust the
pulse lasts frequency it’s either how
■ Overall current fast we are producing a
■ As long as there is contraction
current flowing ○ The higher the frequency,
whether it is positive then the more superficial
or negatively ang na ttarget na muscle
charged and faster yung contraction
○ The lower the frequency is,
○ Phase Duration the slower the contraction
■ Specific with the of the muscle, it can target
polarity deeper muscle due to long
■ Duration of one time travel of the frequency
phase of the pulse *pps : Cameron
*Hz : Michlovitz
○ Interpulse interval
■ Amount of time ● On time
between pulses ○ Time where there is current
■ Off time
● Off time
○ Time wherein there is no
current

● Ramp up / down
○ Amount of time it takes for
the current amplitude to
increase from 0 during the
off time to its maximum
amplitude during its on time

● Amplitude
○ Magnitude of the current or
voltage

● Intensity
○ gaano kalakas yung
electricity
Effects of Electrical Currents Strength Duration Curve
● Graphic representation of the
Stimulation of Action Potentials in Nerves minimum combination of current
● Action Potential (AP) strength (amplitude) and pulse
○ Message unit of nervous duration needed to depolarize a
system particular nerve
● Short pulses and low current
● Resting Membrane Potential amplitudes are used for sensory
○ When a nerve is at rest, stimulation, and longer pulses and
without physiological or higher amplitudes are used for
electrical stimulation, the motor stimulation
inside is more negatively ● Pulse Duration
charged than the outside by ○ <80 ms : produces sensory
-60 to -90 mV stimulation
○ 150 - 350 ms : produce
● Depolarized muscle contractions
○ Can reach up to +30 mV ○ 125 - 250 ms : children and
which causes the frail elderly
permeability to sodium ○ <1ms : mimized pain
decreases and potassium because C-fibers are not
channels rapidly open, depolarized
increasing the permeability ○ >10 ms : produce muscle
to potassium contraction to denervated
muscles
● Absolute Refractory Period
○ When you have your action
potential and it is in
absolute refractory period,
it just mean that it stimulate
other action potential while
it is in this period
○ If the nerve that supplies
that certain muscle is in
absolute refractory period,
you cannot really expect
another contraction from
that muscle

Rheobase
● Relative Refractory Period
● Minimum current amplitude with
○ Comes after absolute
very long pulse duration as
refractory period
required to produce an action
○ You can now elicit AP but it
potential
has to be greater than AP
● Minimum intensity needed to
before
produce AP
● Measure of current amplitude
Chronaxie Ionic Effects of Electrical Currents
● Minimum duration it takes to ● Opposite attract, like repel like
stimulate that tissue at twice ● The negative electrode (cathode)
rheobase intensity attracts positively charged ions;
● Focuses on pulse duration and vice versa
● Measure of time (duration) ● Can be used to provide a force to
increase transdermal drug
*all or none response penetration (iontophoresis)

Action Potential Propagation Contraindications

● Propagation ● Cardiac pacemakers / unstable
○ An AP generated triggers arrhythmias
an AP in the adjacent area ● Placement of electrode over
of the nerve membrane carotid sinus
● In general, with physiological ● Areas where or arterial thrombosis
stimulation, AP propagation occurs or thrombophlebitis is present
in only one direction ● Pregnancy - over or around the
● With electrically stimulated APs, abdomen or low back
propagation occurs in both ○ When in delivery / labor, it
directions from the site of can be applied
stimulation
● If the intensity is too high and you
did not monitor it, it can induced Precautions
seizure → regression of the patient ● Cardiac disease
● Impaired mentation / impaired
sensation
Direct Muscle Polarization ● Malignant tumors
● Neuromuscular Electrical ● Skin irritation / open wounds
Stimulation (NMES)
○ Innervated muscles
contract in response to Adverse Effects
electrical stimulation when ● Burns (commonly seen in DC or
a stimulated AP reaches AC)
the muscle via the motor ● Skin irritation / inflammation
nerve that innervates it ● Painful to some
○ Intact muscles
● Electrical Muscle Stimulation
(EMS) Documentation
○ Denervated muscles The following should be
contract when the electrical documented:
current directly causes the ● Area of the body treated
muscle cells to depolarize ● Patient positioning
○ Requires pulses of ● Specific stimulation
electricity lasting 10 ms or parameters
longer ● Electrode placement
○ Nerves are dead ● Treatment duration
● Patient’s response to
treatment
○ Under assessment
section
 Hazards
● Anode
○ Acidic reaction
● It has been successfully used in ■ Hardening effect
the treatment of numerous ■ Produce mild
conditions heating effect d/t
● Commonly used in rehabilitation - vasodilation
application of corticosteroids ■ Less uncomfortable,
(Dexamethasone) quite safe

● Cathode
Theoretical Basis of Iontophoresis ○ Alkalinic reaction
● Continuous, unidirectional current ■ Softening effect
(DC) – Ion transfer may occur ■ Produce mild
● Most studies have demonstrated heating effect
penetration to a depth of 3-20 mm ■ Cause discomfort
○ Sodium ethanolamine and ■ Skin irritation
lidocaine could be detected ■ Chemical burns
up to 2 cm
● Forces acting to move an ion :
○ Strength of electric field Continuous Direct Current
○ Impedance of the body to ● The current of choice for
current flow iontophoresis
● Velocity of charged ions ● Hazards:
○ Gaano kabilis nag ○ Possible formation of
ppenetrate sa skin electrochemical burn on the
○ Depends on the current skin underlying electrodes
density – can be increased ■ Alkaline reaction
by decreasing the size of under cathode –
electrode / increasing the more caustic
current amplitude (Sodium Hydroxide)
● Principal guide to current density ■ Acidic reaction
○ Would depend on patient’s occurring under
comfort (limit) anode – less caustic
(Hydrochloric Acid)
● Physiological effects of DC on the ● To prevent skin destruction:
skin ○ Current density – not >
○ Anode 1mA / cm2
■ Positive charged ○ Size of electrode
electrode ■ Larger size of
○ Cathode electrode to prevent
■ Negatively charged tissue destruction
electrode ○ Current intensity
○ The surface area of the
**PANIC : Positive is Anode, Negative is cathode at least twice that
Cathode of the anode at all times
■ Mas nag cause ng
discomfort si
 cathode, therefore, ○ Longer duration of current
mas malaki dapat ■ Will result to higher
SA nya para current density
maiwasan
discomfort, etc. Factors Inhibiting the transfer of Ions:
■ It should be at least ● Skin
twice to complete ○ One of the primary function
the current of the skin
■ Increase impedance
Continuous Direct Current and current transfer
● Has anesthetic effect ○ What part of the skin
● Mild to moderate hyperemia on (B) decreases impedance
electrodes ■ It would be the
dermal structures
Transfer of Ions ● Hair follicles
● The effectiveness of a specific ion ● Sweat
will depend upon: glands
○ The number of ions
transferred ● The tendency of some ions to form
○ The depth of penetration insoluble precipitates as they pass
○ Whether the ions combine into the tissue
chemically with other ○ Can actually be formed by
substances in the skin and heavy metal ions
precipitates ■ Iron
○ Whether the ions enter the ■ Silver
capillaries – carried away ■ Copper
from the site of application ■ Zinc
by the blood
● The number of ions transferred into
the human body is related to:
○ The current density at the
active electrode
○ The duration of the current
flow
■ As the duration of
the treatment
increases, the skin
impedance
**2 mA – most recommended, safest,
decreases – current
optimal result when being applied
will have more
transdermal drug
effect – will also
have burns
○ Concentration of ions in the
solution
● The quantity of ions introduced
across the body surface is directly
proportional to the current density
 Size of Electrode
● Electrode should be large enough
– that current density does not
exceed:
○ 0.5 mA / cm2 when
cathode is used as delivery
electrode
○ 1.0 mA / cm2 when anode
is used

**Na – SAD – K = Negative Ions Polarity

● Na - sodium chloride ● The drug delivery electrode should
● S - sodium salicylate have the same polarity as the
● A - acetic acid active ion of the drug to be
● D - decadron delivered
● K - potassium
Current Amplitude
● The amplitude should be
Contraindications for the use of determined by the patient comfort
Iontophoresis and should not be greater than 4
● Allergic reactions mA
● Sensory loss or impairment ● The current must be increased
● Over denuded areas ; over new slowly at the beginning, and
scar tissues decreased slowly at the conclusion
● Metal electrodes must never come of the treatment
in contact with the skin
Treatment Time
● The treatment time is affected by
Parameters for Iontophoresis the current amplitude
● Time should be adjusted to
Electrode Placement produce total treatment dose of
● Drug delivery electrode 40-80 mA - min
○ Is placed over the area of ● In practice, one should set the
pathology current amplitude to patient
● Iontophoresis w/ wired electrodes comfort & then adjust the time to
○ Dispersive or return produce the desired product
electrode is placed few
inches away from Tx Specific Utilization of Iontophoresis
electrode (over a muscle
belly / convenient) Local Anesthetics
Procedures:
● Dental – tooth extraction
● Ear – external auditory canal and
tympanic membrane prior to
surgery
● Nose and Throat
 ● Ophthalmologic – surgery of
conjuctiva

Edema Reduction
● Using hyaluronidase iontophoresis
– reducing edema in acute and
chronic conditions

Inflammatory Conditions
● Bursitis
● Tendonitis
● Ligamentous strain
● Epicondylitis
● Decadron and xylocaine
iontophoresis

Skin Conditions
● Idiopathic Hyperhidrosis – Tap
water Iontophoresis
● Small open ulcers – Zinc Oxide
Iontophoresis
● Fungus infections – Copper
● Antibacterial effect – Silver ion

Other Conditions
● PVD, RA, Varicose Ulcers
○ Histamine and mecholyl
has been used as
superficial vasodilators
● Sclerotic Therapy
○ Iodine Iontophoresis ; for
reducing and stretching of
scar tissue
● Calcium Deposits
○ Acetic acid iontophoresis
 skeletal muscle nociceptors
on the common nerve root
of the spinal cord
■ EX: To the left, to
Pain the left spleen,
● An unpleasant sensory and kidney, stomach to
emotional experience associated the left (referred
with actual or potential tissue pain : left shoulder)
damage or described in terms of ■ EX : gallbladder
such damage - IASP (referred pain : mid
● Perception of pain back)
○ Cultural differences
○ Emotions Pain Pathways
○ Past experiences ● Peripheral Pain Pathway
● A protective sensation ○ Starts w/ nociceptors
○ Pain means there is actual ○ Nociceptors
or potential damage ■ Nn endings of
○ You don’t treat pain if you A-delta & C fibers to
don’t know the cause CNS
■ Found in the skin,
Types of Pain mm, joints, bone
● Acute and viscera and has
○ Pain lasting than < 12 high threshold for
weeks activation
○ Associated w/ actual ■ After tissues injuries
physiological event and inflammation,
○ VS is warranted body releases
substances that
● Chronic sensitize these
○ Existing for 3-6 months receptors
○ Associated w/ physical,
emotional, social, and ○ A- Delta Fibers
financial disability ■ Fxn as the 1st of
○ Clinicians must rely on a pain sensation
multidisciplinary approach ■ Precise location of
and should involve more noxious stimuli on
than one therapeutic the body and
modality generation of
○ It does not need to be more withdraw reflexes
than 3 months sometimes if
it exceed to the expected ○ C-Fibers
time of healing, it is ■ Respond to a broad
considered as chronic pain range of painful
stimuli
● Referred ■ Considered 2nd
○ d/t convergence of pain
cutaneous, viscera;, and ■ Prevent further
tissue damage
 ■ Characterized as
slow, dull, aching,
burning, and long
lasting

● Central Pain Pathway

○ 2nd order neurons
■ Aka central
nociceptive
transmission
neurons because
● Comes from the Right side
they transfer the
○ Decussate / cross → move
nociceptive
upwards going to
impulses from the
contralateral hemisphere of
spinal cord and
the brain
brainstem to the
● The decussation does not happen
higher centers of
immediately – it would ascend first
the brain
to same side and after certain
levels of the nerve, it will cross and
○ Spinothalamic tract
go up
■ Main pathway for
○ 3 levels up (ipsilateral)
pain from somatic
and visceral tissue
*sensory - ascend
*motor - descend
○ Spinoreticular tract
■ For suppression or
facilitation of pain
and are involved in
the motivational,
emotional, and
unpleasant
components of pain

○ Spinomesencephalic tract
■ Terminates at
periaqueductal grey
area (PAG)
■ Activates a
descending
pathway that
promotes analgesia
(serotonin)
 ● Use of transcutaneous electrical
stimulation to modulate pain
● Main mechanism : activation of
peripheral opioid receptors and
opioid receptors within CNS

● Low rate / low frequency /

Modes of TENS acupuncture like TENS
● Conventional TENS ○ Involves repetitive
○ Aka high rate TENS stimulation of motor nn to
○ Uses short duration higher produce brief repetitive
frequency pulses at a muscle contractions or to
current amplitude produce brief sharp pain
○ Theory : gate control theory which can stimulate
■ Mimic paresthesia – endogenous opioids
activate A-Beta production and release
■ This activates ■ If the frequency is
A-beta fibers to less than 10 Hz /
produce pps
comfortable ○ May control pain by
paresthesia stimulating the production
○ Highly recommended for and release of endorphins
acute pain conditions and enkephalins
○ May be used for up to 24 ○ Uses longer pulse duration
hrs a day if necessary and higher current
○ Stimulus used for amplitude
conventional TENS is ○ Activates A-beta and
generally modulated to limit A-alpha nn fibers that leads
adaptation to rhythmic muscle twitches
■ Adaptation is ○ Controls pain for 4-5 hrs
decrease in the after 20-30 mins tx but
frequency of AP and shouldn’t be longer than 45
a decrease in the mins because it could
subjective sensation cause DOMS
of stimulation when ○ Adaptation occurs at 4th to
electrical stimulation 5th day of stimulation
is applied w/o ○ TENS induced analgesia
variation in the solution
applied stimulus ○ Recommended for chronic
○ Activates A-beta nn fibers pain conditions
● Burst Train TENS Analgesic Mechanisms
○ Stimulation is delivered in
bursts Analgesic Mechanisms of Low Frequency
○ Same mechanism with TENS
LRAT but may be more ● Low frequency activates increased
effective because more release of serotonin
current is being delivered ● Produces antihyperalgesia by
○ Produce a more triggering descending inhibitory
comfortable muscle pathways
contraction ● Blockade of peripheral opioid
○ Recommended for chronic receptors by naloxone (Narcan) at
conditions the site of application counteracts
the low-frequency TENS

Analgesic Mechanisms of High Frequency

TENS
● Increases the concentration of
Beta endorphins in the
bloodstream and cerebrospinal
fluid
● Reduces glutamate and aspartate
release
○ Pain sensitizing substances
● Brief Intense TENS – associated with chronic
○ Used to provide short local pain
hypoalgesia during minor ● Reduces substance P in SC and
painful procedures periphery
○ Rarely used d/t discomfort ○ Pain sensitization – specific
○ Last to be considered as in the spinal cord and
TENS mode periphery
■ Wound dressing
changes
■ Skin debridement
■ Suture removal
■ Venipuncture
Analgesic Tolerance and TENS Documentation
● Repeated application of either low ● Area of the body to be treated
or high freq TENS can also result ● Patient positioning (optional)
in analgesic tolerance ● Specific stimulation parameters
● Tolerance attained w/ opioid ● Electrode placement
medication could also affect TENS ● Treatment duration
tolerance post operative ● Patient response to treatment
● Chronic pain pts respond better w/ (under assessment part)
high freq TENS but consider
asking for pharmacological Hx

Stimulus Intensity
● Increasing pulse amplitude by 10%
per day of both low and high freq
TENS delayed the onset of
analgesic tolerance
● Appropriate stimulus intensity is
critical for successful TENS
application
- Heart rate, Respiratory rate, etc.

Caffeine Consumption and TENS

● Caffeine a competitive adenosine
receptor antagonist, may interfere
with TENS effectiveness
● Monitoring caffeine intake before
treatment is essential to maximum
the analgesic effect of TENS

Contraindications
● Demand pacemaker / unstable
arrhythmias
● Over the carotid sinus
● Venous or arterial thrombosis /
thrombophlebitis
● Pelvis, abdomen, trunk, and low
back during pregnancy

Precautions
● Cardiac disease
● Impaired mentation / sensation
● Malignant tumors
● Skin irritation / open wounds
 collagen and protein
polysaccharides

● Maturation phase
Electrical Currents for Tissue Healing ○ 3rd phase of wound
● ES can also contribute to a healing, longest phase
rehabilitation program by ○ A wound is considered
promoting tissue healing closed at the time
○ Tissue healing may be epithelium covers the skin
prompted directly by surface; reduction of
applying the current to a number of fibroblasts,
wound or may be promoted decrease vascularity d/t
indirectly by controlling decrease metabolic
edema / promoting demand, remodelling of
transdermal delivery of collagen
medication ○ It starts when the wound
closes
● Galvanotaxis ○ Scar formation / scar
○ ES promotes tissue healing formation itself
primarily by ionic effects,
attracting or repelling
charged entities General Factors associated w/ Inadequate
Healing and Repair Responses
Wound Healing Phases ● Inability to form a blood clot or
● Inflammatory phase mount an adequate inflammatory
○ 5 cardinal signs reaction
■ Functional limitation ● Inability to produce a new cells or
■ Redness scar components in adequate
■ Swelling quantity or quality
■ Pain ● Inability to organize the scar into
■ Heat an appropriate functional or
cosmetic unit
● Proliferative phase ○ Hypertrophic scar
○ 2nd phase of wound ■ It is within the
healing borders of the
○ Re epithelialization, is wound
occurring at the surface of ○ Keloid scar
the wound, while deep ■ Goes beyond the
within the wound, border of the wound
fibroblasts are migrating
and proliferating; Collagen Wound Healing
Deposition and wound ● ES for treatment of :
contraction ○ Chronic stage III or stage
■ Fibroblast are the IV pressure ulcers
cells that synthesize ○ Arterial ulcers
scar tissue, which is ○ Diabetic ulcers
composed of ○ Venous stasis ulcers
Electrical Stimulation to promote Wound conjunction with standard wound
Healing care
● Most recent systematic review,
published in 2011: How Electrical Stimulation Facilitates
○ Healing of various types of Wound Healing
wounds can be facilitated ● Electrical stimulation:
by electrical stimulation ○ Attracts appropriate cell
types to the area
● Animal studies have demonstrated ○ Activating the cells by
that ES increases altering cell membrane
○ DNA function
■ Considered to be ○ Reducing oedema
the auto ○ Increasing protein
reproducing synthesis and cell migration
component of ○ Enhancing antimicrobial
chromosomes and activity
the repository of ○ Promote circulation and
hereditary improving tissue
characteristics oxygenation
○ Protein
■ Is ¾ of the dry ● Specific cells
weight of most cell ○ Neutrophils,macrophages,
matter and lymphocytes, and
○ ATP fibroblasts – can be
■ Can provide 3 attracted to an injured
strong muscle healing area by an
contraction electrical charge
○ Increase intracellular ➢ Neutrophils
calcium ○ mature WBC
■ initiates cellular
activation ➢ Macrophages
○ VEGF production ○ Phagocytic cells in
nature
● In human studies
○ Increased microcirculation ➢ Lymphocytes
and tissue perfusion and ○ For immune
significantly reduced wound response
area
○ ES was most effective for ➢ Fibroblasts
accelerating the healing of ○ Formation of new
pressure ulcer scar tissue
○ Increase tissue
oxygenation and reduce ● ES can trigger opening calcium
discomfort channels in the fibroblast cell
membrane – the open channels
● ES aids in wound healing, allow calcium to flow into the cells,
particularly when applied in increasing intracellular celsius
levels – it induce additional insulin
 receptors on the cell surface – ● Positive Electrode
insulin can bind to the exposed ○ Inactive neutrophils
receptors, stimulating the ○ Macrophages
fibroblasts to synthesize collagen ○ Epidermal cells
and DNA (this can happen with ○ Should be used if necrosis
HVPC, with peak V 60-90 V) w/o inflammation is present
○ Fibroblasts and collagen and when the wound is in
are essential for the the proliferative stage of
proliferation phase of tissue healing
healing
Contraindications for the use of electrical
● Monophasic currents, (B) currents for tissue healing
microampere level Direct Current ● Demand pacemaker or unstable
(DC) and HVPC – have been arrhythmias when electrical
shown to kill bacteria; not in AC
*higher duration and voltage ● Stimulation is delivered with a
should be employed to effectively stimulation unit
manage bacteria ○ Over the carotid sinus
○ Venous or arterial
● ES facilitates healing by increasing thrombosis or
circulation during or after thrombophlebitis
stimulation ○ Pelvis, abdomen, trunk,
and low back during
pregnancy
ES might accelerate wound healing as a
consequence of : Precautions for the use of electrical
● Activation or attraction of currents for tissue healing
inflammatory cells ● Cardiac disease
● Attraction of connective tissue cells ● Impaired mentation or sensation
● Enhanced cell replication ● Malignant tumors
● Enhanced cell biosynthesis ● Skin irritation or open wounds
● Inhibition of infectious ● Applying near wounds
microorganisms ○ It is common for patients
not to have intact sensation
Specific Electrode Polarity in these areas – lower
● Negative Electrode : to promote amounts of stimulation
healing of inflamed or infected
wounds ● Infection control
○ Activated neutrophils ○ If electrodes are placed in
present in inflamed and wounds, a new electrode
infected wound should be used each time
○ Lymphocytes ○ Self adhesive electrodes
○ Platelets should be single patient
○ Mast cells use only
○ Keratinocytes ○ Chronic wound should be
○ Fibroblasts kept clean
○ Protective covers for
electrical stimulation
 devices leads to minimize ■ Early inflammatory
transmission communicable stage of healing
disease (MRSA) – not ■ First 3-7 days of
responding to antibiotics, treatment → change
highly infectious to positive
■ 3 days after wound
Parameters for Electrical Stimulation to bed becomes free
Promote Wound Healing of necrotic tissue,
● Electrode Placement and drainage
○ Treatment electrodes may becomes
be placed in or around the serosanguinous –
wound use of positive
○ 1 treatment electrode is polarity
used when treatment
electrode is placed directly ○ Positive polarity
in the wound ■ Later part, to
○ 2 or more treatment facilitate epithelial
electrodes may be used cell migration
when stimulation is applied
to the area around the ○ Consistent with many
wound recommendations
○ If directly over the wound – ■ Negative polarity :
the electrode should be initial treatment,
made to fit the wound – the when wound shows
type of electrode is made signs of
by placing saline - soaked inflammation
gauze directly in the wound ■ Positive polarity :
and then covering this with when the wound
a single use disposable shows no signs of
electrode, multi use carbon inflammation or
rubber electrode, or a layer when healing
of heavy duty aluminum foil plateaus
○ If around the wound – self
adhesive electrodes are
recommended
○ 1 large dispersive
electrode, of opposite
polarity to the treatment
electrode, should be placed
on intact skin close (several
inches away) to the wound
site
Edema
● Edema is a normal response
● Polarity
following to tissue trauma
○ Polarity of electrode =
○ Potential systemic d/o
accdg to the types of cells
○ Accumulation of fluid that
required
produces swelling
○ Negative polarity
 ● Can have protecting effects ○ Acceleration of functional
○ Splinting the injured area activities
○ Component of 1st stage of
tissue healing –
inflammation Edema due to lack of muscle contraction
○ Associated with increased ● Edema formation
pain, decreased function, ○ lack mm contraction
and prolonged recovery
● Motor level electrical stimulation
Edema due to inflammation (+) limb elevation – increase
● Edema secondary to inflammatory popliteal blood flow
response ○ Edema secondary to LE
○ Red and warm surgery or
thromboembolism (after
● Electrical stimulation during addressing)
inflammatory response:
○ Retard the formation of ● Not with NMES sensory level
edema
■ Negative HVPC –
roughly 50% after
acute injury –
similar w/ ibuprofen
and cool water
immersion

○ Not with (+) HVPC and

biphasic current
Electrode Placement
○ HVPC shown to be
● Associated with inflammation
effective d/t ff mechanisms
○ Negative polarity
■ (-) charged repels
■ Treatment
(-) charged serum
electrodes should
proteins – blocking
be placed directly
their mov’t out of
over the area of the
blood vessels
edema
■ Current decreases
blood flow by
○ Dispersive electrode
reducing
■ Placed over the
microvessel
another large flat
diameter
area proximal to the
■ Reduction in pore
area of edema
size in microvessel
walls, preventing
● Associated w/ lack mm contraction
large plasma protein
○ Electrodes should be
from leaking
placed on the muscle
through pores
around the main veins
draining the area in the
 same way as
recommended for mm
contraction

Electrical Activity in the skin related to

wounds and healing
● Fibroblastic activity, epidermal cell
orientation and migration have
been demonstrated in DC fields
● Antibacterial effect – (+) / (-)
HVPC
● Collagen content and increased
wound tensile strength – DC
stimulation at 40 – 400 mA
● Wound closure – (B) AC and DC –
showed the most rapid reduction in
the wound area; AC – most rapid
reduction of wound volume
● Tissue Necrosis - DC stimulation
 ES of mm contractions can accelerate and
improve rehabilitation:
● increasing strength and endurance
● Enhance quality of motor
recruitment
Muscle Contraction in Innervated Muscle ● Improved performance of
functional activities
Physiology
● Need an AP coming from the nerve To increase strength
to excite the muscle to cause ● Higher force of contractions should
contraction be used
● Travel of AP
To increase endurance
Characteristic of Contraction ● prolonged stimulation w/ low force
Physiologic Muscle Contraction contractions should be used
● gradual motor recruitment and rate
of motor unit activation, Healthy mm - to produce strength gains in
asynchronous recruitment of motor healthy muscles
units producing smooth, gradually ● atleast 50% of MVIC force
increase in force ● Test gains : max tolerated force of
● 1 direction contractions

Electrically Stimulated Post Injury - to produce strength gains

● motor units fire simultaneously post injury
when the stimulus reaches motor ● initially have a force of 10% MVIC
threshold producing generally rapid
and jerky
● 2 directions (to the machine, to the MVIC
higher center) ● maximum voluntary isometric
contraction : MVC - maximum
voluntary strength or contraction
ES for muscle strengthening ● It is the maximum tension
● Overload Principle developed against an unyielding
○ may also apply to resistance in a single contraction
contractions produced by ● Typically generated for a short
ES and physiologically duration over 5 secs
○ Higher load to obtain higher ● Higher force of contractions should
power of muscle be used
○ “Intensity of load” —
increased intensity Neuromuscular Electrical Stimulation (no
mov’t)
● Specificity Principle ● the use of electrical currents to
○ Increased reps if you want produce muscle contractions in
to be good at it innervated muscles
○ Target specific muscle / ● Required an intact and functioning
training PNS
● Commonly used at sufficiently high
intensities to produce muscular
 contraction — may applied during Contraindications
mov’t or w/o functional mov’t
● Has shown effective in : stroke, Parameters :
SCI, sports related injuries and ● Pulsed Biphasic Waveform /
post op conditions Russian Protocol
● Goal : strengthen the muscles,
improve cardio health, retard / ● Russian Protocol
prevent muscle atrophy, reduce ○ big machine
spasticity, and motor function ○ MFAC : freq of 2500 Hz
delivered in 50 burst per
second (burst and IBI
Functional Electrical or Neuromuscular duration : 10 ms)
Stimulation (FES / FNS)
● when aim of treatment is to Electrode placement
enhance or produce functional ● one electrode — motor point
movement ● Other electrode - on the muscle to
● Mode — mm strength : Gr. 2+ to 3- be stimulated
● Electrodes should be aligned to
Evidence of Clinical Efficacy each other

Strengthening of Non-Neurological Patient Positioning

Conditions ● when mov’t is not contraindicated
● Muscle can be contracted
2 mechanisms isotonically during stimulation all
● strength gains may be achieved in throughout ROM
the same manner as standard
voluntary strengthening Duty Cycle
programmes ● relaxation is needed to limit fatigue
● Low reps x high intensity of muscle
contraction Recommended :
● Strengthening occurs through ● 6 to 10 s ON
preferential recruitment of type II ● 50 to 120 secs OFF
phasic muscle fibers
Strengthening
Type II muscle fibers ● initial ratio of 1:5
● first to be activated by the ES ● To minimize fatigue
● fast atrophy ● Progression of 1:4 or 1:3
● ex : quads, biceps brachii, etc.
● Have high threshold for NMES To relieve spasm / pump out edema
● 1:1 ratio (on and off in between
Type I 2-5s)
● ex : trapezius, erector spinae,
temporalis *no contractions — fatigue muscles
Treatment Time Effects of NMES
For muscle strengthening ● direct result of mm strengthening
● treatment last long enough to allow ● increased general excitability of the
10-20 mm contractions = ~10 mins motor neuron — through ES —
● Repeated multiple times per day enhancing descending control of
● Time can be adjusted according to mm recruitment
the desired number of contractions ● CNS dysfunction w/ intact PNS :
TBI, MS, CP
For muscle re-education ● CNS STROKE, SCI : as long as
● time will vary based on functional peripheral nervous system is
activity intact; in case of LMN - the muscle
● No longer than 20 mins NMJ junction and the muscle be
intact
● Can also improve muscle strength
Clinical Applications of Electrically with an intact central and
Stimulated Muscle Contraction peripheral nervous system
● FES can be integrated into
Orthopedic condition performance of functional activities
● based on overload and specificity by stimulating contractions at the
principle can accelerate recovery : time during an activity when the
● Type II mm fiber atrophy induced muscle should contract
by immobilization and rest
● Quads strength ff ACL injury : SCI
reconstruction of TKA — total knee ● ES does not reverse SC damage
atrophy ● Reduced common complications
● NMES for quads strength prior to — improving quality of life
operative management
● NMES was effective as exercise in NMES use:
decreasing pain ● counteract disuse mm atrophy
● PFPS — patellofemoral pain ● Improve circulation
syndrome — pain posterior to the ● Assist in locomotion
patella ● Grasp ; aerobic and cardio
conditions
In aging ● IFES : bowel and bladder voiding,
● there is a relative decrease in type respiration
II mm fibers
For FES to be effective:
● improving quads strength is ● it must produce a contraction of
important rehabilitation because, sufficient force to carryout the
post op weakness can decrease desired activity
function and increase disability and ● It must not be painful
fall risk ● It must be able to be controlled and
repeated
Neurological Condition
● can also increase strength and
improves motor control in patients ● FES can also be incorporated with
with CNS damage leg cycle ergo, arm cranking,
rowing — increasing the strength,
 endurance, decrease mm atrophy,
increase energy expenditure,
increase blood flow, increase O2
uptake, stroke volume, ventilatory
rate, max O2 consumption

Strokes
● stimulation of agonist : can
improve voluntary recruitment of
motor units
● Stimulation of antagonist : reduces
spasticity, activating reciprocal
inhibition of agonist muscle
● Sequential stimulation

Shoulder Subluxation
● NMES in 6 wks program was more
effective than in facilitation
program
● Substitute for AFO

NMES to decrease
● Pain
● Edema
● Hypertonia

● FES facilitated cycling reduced

spasticity significantly—more than
cycling alone
 ● Atrophy
○ Shrunken / wasted muscle
○ Etiology
■ Caused by a lot of
Stimulating Denervated Muscle factors
● Maintain it in as healthy state as ○ Types
possible – while awaiting for ■ Physiologic atrophy
re-innervation ● Diffuse
● Features : innervated muscles vs. atrophy
denervated muscles ● Hindi
○ Using ES masyado
■ Substitute for ginagamit
physiologic mm kaya
contraction nag-atrophy
■ Prevent negative ■ Pathologic atrophy
changes ● Was caused
■ Maintain muscle by a aging,
integrity certain
■ Remain functional diseases
● “Highest goal to denervated ■ Neurogenic atrophy
muscle is from retard atrophy – ● Most severe
maintain muscle integrity” ● Caused by
● “Highest goal to innervated muscle injury
is to reach normal – normal directly to
function” the nerves
itself →
What happens to denervated muscle neuromuscul
before re-innervation? ar complex
● Consequences of interrupted ○ Investigation
peripheral neural arch: ■ Quantitative
○ Loss of voluntary activity methodology
○ Loss of reflex response ● Macroscopic
○ Progressive muscular technique
atrophy (weeks or months) (muscle
itself) :
Denervation, Muscle Atrophy, Fibrosis weighing a
● Denervated muscle denervated
○ Paralysis and wasting of a muscle and
muscle to a greater extent comparing it
○ Fibrillating to the
○ Marked hypersensitivity to contralateral
Ach (acetylcholine) ● Microscopic
○ Different chronaxie level technique
and strength-duration (muscle fiber
relationship itself) :
○ Sluggish contraction using measuring
LDMC diameters or
areas of
 denervated compensates for the
muscle greater atrophy of the fiber
fibers and
contrasting Steps must be taken to maintain muscle
values to the integrity?
contralateral ● Limit edema and stasis
limb ● Maintain flexibility of the part
■ Assesses ● Avoid further injury to the muscles
specifically at the as much as possible
individual mm fiber

Other Changes with Denervation

Sunderland Review of Muscle Atrophy ● Fibrillation
● Atrophy ○ spontaneous ,
○ Rapid initial loss of weight uncoordinated contractions
○ 29 days : muscle is of individual muscle fibers
sustaining 30% loss ■ Persistent fine
○ 60 days : increases to rippline of the
50-60% mm loss surface of an
○ 120 days : process is exposed denervated
slower; stable state; weight mm
loss between 60-80% ● Acetylcholine Hypersensitivity
○ Generally, marked loss of ○ Law of Denervation
weight within first 2 months Hypersensitivity
○ Microscopically: ■ After a period of
■ Type II fibers time, a denervated
atrophy to a greater structure (which
extent than type I could be sk mm,
muscle fibers smooth mm, gland
becomes
Denervation, Muscle Atrophy, Fibrosis hypersensitive to
● Fibrosis agents that normally
○ The percentage decrease activate it)
of muscle fiber ■ Ach receptors,
circumference – loss in which are normally
muscle weight present only in the
■ Loss of muscle fiber end plate region of
○ “Reduction in fiber calibre the sarcolemma,
–relative increase in become
connective tissue” incorporated into
○ The difference between the the entire length of
weight loss and the the fiber’s
reduction in fiber calibre is membrane
accounted for by the
relative increase in the
amount of connective
tissue – which
 ● Membrane Changes Parameter – Effects
○ RMP of denervated mm fall ● EMS
○ Transmembrane resistance ○ Monophasic pulses
increases ○ Intensity
○ Denervated endplate ■ Strong enough to
membrane develops produce “vigorous”
pacemaker characteristics muscle contraction
(they rhythmically produce ○ Typical 20 min treatment
Ach at their own regulation ■ Producing 500-600
of rate) single contractions
■ Spontaneous ○ 1 pps for 20 min daily
fibrillation ■ No contracture
formation
● Electrical and Mechanical Changes ■ Significant less
○ Short duration electrical atrophy
pulses – no muscle ○ Pulse frequency
response ■ 1 Hz/pps
○ LD pulse currents – >10 ○ Pulse duration
ms; low freq stimuli ■ 300 ms
■ Denervated mm will
contract sluggishly ● Effects
○ Changes in chronaxie and ○ Delayed / diminished
SD curve atrophy
○ “As the pulse duration is ○ Muscle fiber were larger
shortened, higher current ○ Connective tissue less in
amplitude will be needed to treated mm
achieve the same strength ○ Rate of re-innervation
of contraction produced by increased
a longer pulse duration” ■ Reflex or voluntary
function
EMS in Denervation
Facts
● ES only retard muscle atrophy, not Contraindications – Precautions (same as
preventing it: usual)
○ Only superficial fibers were
activated by stimulation
○ Number of contractions per Electrical Muscle Stimulation
day was insufficient ● Biphasic waveform with a 120 to
■ You do not apply ES 150 millisecond pulse duration
24/7 ○ Individuals with complete
■ ES is applied LE LMN denervation d/t
around 10-30 mins Cauda Equina Injury
○ Change in muscle – is not
simply as an “inactivity ● Electrode placement
atrophy” ○ Area where electrical
stimulus will produce the
greatest contraction with
 the least amount of
electricity
○ Place the electrode at the
motor point

● Patient positioning
○ Limb can be secured to
prevent motion through the
range
■ Allowing isometric
contraction at
midrange
■ Secured by means
of barrier / weighted
cuffs