Course Title: Electrotherapy in Physiotherapy II
Course Code: BPHY302
Ms. Jessica Rauszen
(Email:
[email protected])
Lecture 9: Stimulation of afferent nerve including microcurrent and
electroacupuncture
Decision making in the clinical application of novel and contemporary modalities &
Record and analysis of treatment methods, parameters and clinical outcomes
CILOs
1. Demonstrate understanding in the physics, anatomy and physiology of
microcurrent, pulsed electromagnetic field, biofeedback, laser, and ultraviolet
radiation, functional electrical nerve stimulation, and electrical stimulation in
the context of management of most of the common neurological conditions.
2. Appreciate the biophysical and therapeutic effects of various electrophysical
agents in electrodiagnosis, pain modulation, wound management and
integumentary repair using electrophysical modalities to reduce edema and
promote nerve repair.
3. Evaluate the use of various electrophysical agents in terms of their physical
properties, therapeutic effects, and versatility in clinical applications, and their
potential health benefits or risks.
4. Devise a safe, effective and efficient treatment plan with the use of the most
appropriate electrophysical agent based on the analysis of the clinical
presentation and evidence supporting the use of a given electrophysical
modality.
Uses of electrical stimulation
Motor Sensory
Other uses Iontophoresis
Stimulation Stimulation
• Strengthening • Pain • ↑Blood flow • Not a form of
(MMT, ROM management • Effects on electrical
etc) • Influence ANS stimulation;
• Functional changes in • Wound and use of
CNS fracture electrical
healing current
• ↓Oedema
References on Electroacupuncture
Perreault, T., Flannagan, S. O., Grubb, M. T., & Grubb, R. (2018). Mechanisms
and dose parameters of electric needle stimulation: clinical considerations—
part I. Acupunct Electrother Res, 30(2), 17-26.
Pearce L. Electricity and electroacupuncture – a quick overview. Acupuncture
in Physiotherapy. 30(2): 105 – 107
Chan MWC, Wu XY, Wu JCY, Wong SYS, Chung VCH. Safety of Acupuncture:
Overview of Systematic Reviews. Sci Rep. 2017 Jun 13;7(1):3369. doi:
10.1038/s41598-017-03272-0. PMID: 28611366; PMCID: PMC5469776.
Definitions
Acupuncture: uses meridians, based on the diagnostic and clinical reasoning
approach of Traditional Chinese Medicine. This entails comprehensive
knowledge of the 5 element theory, tongue and pulse assessment.
Dry Needling: aimed at myofascial trigger points(MTrP) which are
hyperirritable spots in skeletal muscle. Trigger point dry needling can be
carried out at superficial or deep tissue level.
Western acupuncture: uses meridian points but applies it to western
scientific reasoning with consideration to anatomy and neuro-physiology.
Electro-acupuncture: inserted needles can be coupled to the electrodes of an
electroacupuncture machine. These units are designed to deliver variable
amplitudes and frequencies of electrical impulses.
Basic concepts
What happens during acupuncture, dry needling
and EA?
➢Manual stimulation as needle is inserted into the
body
➢Manipulation of needle is needed to activate
local, spinal and supraspinal analgesic effects
How are points chosen in ‘western dry needling?’
Meridian points / dermatomal or segmental
pattern / MTrP / ah-shi point …..
How are parameters identified for needling?
▪ Strength of manipulation
▪ Number of needles
▪ Repeated sessions
Needling as a form of afferent stimulus
❖ Electric needle stimulation (ENS) provides superior analgesic effect
over manual needling for managing chronic pain in NMSK disorders
Parameters identified for greater anti-nociceptive effects:
➢ Intensity dependent
➢Needle placement within segmental distribution of pain
➢Duration of EA (15 to 30 minutes) lasts for longer – 5 minutes is short
duration and may bring strong fast onset analgesia for a few minutes
Primary Mechanism of EA-induced
analgesia [Perrault 2018]
❑ Induces segmental inhibition
❑ Local analgesic effects
❑ Reduces inflammatory pain
❑ Triggers descending pain inhibition
❑ Induces supraspinal analgesic effects
Intensity dependent effects
➢Segmental analgesia may be triggered
by low intensity EA to a local point on
the side of pain
➢At higher intensities, EA ↑ pain
thresholds within and beyond
segmental distribution on the
ipsilateral and contralateral side
- As intensity ↑and surpasses Aδ and
C-fibers → longer pain relief due to
depression of C-fiber reflex response
- Contralateral stimulation to same
acupoint on the contralateral side
produces segmental effect only if
noxious stimulus is used
Analgesic mechanisms of EA
NOXIOUS EA (80 – 120Hz) LOW FREQUENCY EA (2 – 15Hz)
Greater pain inhibition at spinal and supraspinal
level
Induces anti-nociceptive effect in periphery
↑ spinal serotonin (5-HT) ↑availability of target
Ariginine vasopressin ↑anandamide level
receptor
and noradrenaline (NA)
NA and 5-HT activates
Upregulates endogenous opioid system in
Amplifies effect of descending periphery
supraspinal neurons that project
pain inhibitory systems
to the level of the spine
Safety of acupuncture [Chan 2017]
• Adverse events
• Organ or tissue injuries (incl. broken or remnant needles)
• Infections
• Local adverse events / reactions
• Other complications (e.g. dizziness or syncope)
Safety of EA [Zheng 2010]
• 1979 – 2010
• Case reports, case series, surveys, observational studies on use of
EA
• Fifteen articles with 44 cases of AEs after EA were reported:
• general AEs (n=7) 4 traumatic events, 2 cases of fainting, and 1 case of
hyperventilation syndrome
• specific AEs (n=37) spastic injury (e.g., fracture of the femur head and
dislocation of the wrist joint), electrical injury, atrioventricular block,
aggravated bulbar palsy, and “others.”
ITO ES-160
Channel 1 – 6
Intensity
Program: Continuous, Burst, Surge,
Fast + Slow, Sweep
Frequency (Hz)
Pulse duration (µs)
Duration (minutes)
ITO ES-160: learning to use the machine….
What is electrophysical therapy?
▪ Electrophysical agents (EPAs) are those modalities that administer
thermal, (mechanical), electrical or light energy to the patient to
provide physiological effects and therapeutic benefits. They are
primarily used in physiotherapy practice as an adjunct to other
treatment and management techniques.
▪ EPAs are used to relieve pain, reduce swelling, increase local blood
flow and break down scar tissue and can be useful in assisting with
early, mid and late injury management.
▪ They may be used as assessment and as treatment
▪ It is a tool that, when applied at the right time, at the right dose and
for the right reason, has the capacity to be beneficial
Evidence based practice [Behrens, 2021]
What’s best practice? PICO acronym:
Also known as standard of care, it Patient and problem: gender,
involves the appropriate use of the ethnicity, age, primary complaint,
current best evidence in making diagnosis and history?
clinical decisions Intervention: physical therapy,
Clinical experience medication, test?
Operationalised in protocols, which Comparison: any alternatives to the
provide a step-by-step framework for selected intervention?
implementing guidelines Outcome: desired goal? What
symptoms/function/test scores have
changed?
Patient-centered medicine
• The holistic treatment of the → Patients are experts in the
patient experience of their symptoms
• Humanistic, biopsychosocial → Patients are different in
approach preferences in health care (even if
• Patient participation in clinical they have the same disease and
decision making symptoms pattern)
• In-depth communication to → Much of health care depends on
understand patient complaints the patient’s adaptation and coping
capabilities
• Involves context, preferences,
culture, beliefs, background, → Your role is the teacher /
behaviours and emotional status consultant
Clinical decision making
Clinical data
Clinician’s expertise and
experience
Patient
Research
preference
Evidence
and actions
Using your clinical reasoning and applying to
your patient
Model of Electrotherapy
1. Evaluate patient S/E and O/E
2. Differential diagnosis – use your
available PT tests
3. Therapeutic goals based on stage
of healing, pathology and your
knowledge of modality mechanism
of action
4. Plan of action with patient to
reach goals
5. Administer therapeutic
interventions
6. Repeat steps 1 – 5 and adjust
7. Continue until patient’s condition
resolves
Dosage
• Frequency windows
e.g. TENS, US, IFT, SWD etc.
• Amplitude windows – depending
on skin resistance, patient
response, therapeutic effect etc.
❑ Effective treatment doses and
windows are different in acute
and chronic conditions
❑ Different treatment response in
‘normal’ and ‘injured’ tissues at
equivalent doses
So how do I choose the correct modality as
adjunct to my physiotherapy treatment?
➢ Appropriate modality chosen for
the stage of healing based on clear Exercise
assessment, rationalisation of Advice
prescription
problem and proposed treatment
plan that matches individual needs in
holistic manner Individualized
treatment
➢ Correct dosage!!!
➢ Re-evaluate outcome – some Electro-
modalities have an immediate Manual
outcome, others need certain time therapeutic
Therapy
Modalities
EPT modalities are not prescribed as isolated treatments!
References
• Brook, P., Connell, J., & Pickering, T. (2011). Physical therapies. In
Oxford Handbook of Pain Management. Oxford University Press.
https://doi.org/10.1093/med/9780199298143.003.0009
