Foundations of Electrical Stimulation

Introduction

Electrical stimulation is one of the oldest and most

effective modalities in physical therapy. Despite the wide
variety of electrical stimulators available today, they all
serve a common purpose: stimulating tissues for
therapeutic benefits. These tissues can be categorized
into:

 Excitable tissues (e.g., nerves, muscles)

 Non-excitable tissues (e.g., bone, cartilage)

To understand the effects of electrical stimulation on

different body tissues, it is essential to study the types,
forms, and characteristics of electrical currents.

Components of Electrical Currents

 Atomic Structure & Charge Movement:

All matter is composed of atoms containing positively
and negatively charged particles called ions. These
charged particles have electrical energy and
naturally move from areas of higher concentration
to lower concentration.
  Electrons & Electrical Current:

o Electrons are negatively charged particles with

very small mass.

o Their net movement forms an electrical

current.

o This flow of electrons always moves from a

higher potential to a lower potential.

Measurement of Electrical Current

 Ampere (A): Measures the rate of electrical

current flow.

o 1 ampere (A) = movement of 1 coulomb (C)

per second.

o Coulomb (C): Represents the number of

electrons.

 Units in Therapeutic Modalities:

o Milliampere (mA) = 1/1000 of an ampere.

o Microampere (µA) = 1/1,000,000 of an

ampere.

 Electromotive Force & Voltage:

 o Electrons move only when a potential
difference exists between two points.

o Volt (V): Measures the electromotive force

needed to drive electron flow.

o Defined as the difference in electron

population (potential difference) between
two points.

Measurement of Electrical Current

 Ampere (A):

o Indicates the rate at which electrical current

flows.

o 1 A = movement of 1 coulomb (C).

o Amperes measure the rate of electron flow,

while coulombs measure the number of
electrons.

 Units in Therapeutic Modalities:

o Milliamperes (mA): 1/1000 of an ampere.

o Microamperes (µA): 1/1,000,000 of an

ampere.

 Electromotive Force & Voltage:

 o Electrons will not move unless there is an
electrical potential difference in the
concentration of charged particles between two
points.

o Electromotive force (EMF): The force required

to produce electron flow.

o Volt (V): Defined as the difference in electron

population (potential difference) between two
points.

Voltage, Resistance, and Ohm’s Law

 Voltage (V):

o The force resulting from an accumulation of

electrons at one point in an electrical circuit.

o Usually corresponds to a deficit of electrons at

another point.

o When the two points are connected by a

suitable conductor, the potential difference
causes electrons to move from the area of
higher population to lower population.

 Resistance (R) / Electrical Impedance:

 o The opposition to electron flow in a conducting
material.

o Measured in ohms (Ω).

o A circuit with higher resistance (Ω) will have

less current flow (A) than a circuit with lower
resistance at the same voltage.

 Ohm’s Law:

o Defines the relationship between current (I),

voltage (V), and resistance (R):

o I=V∕R

o Current (I) is directly proportional to

voltage (V) and inversely proportional to
resistance (R).

Material Classification:

o Resistors (Insulators) vs. Conductors:

 Materials are classified based on the

number of free electrons.

 More free electrons → better conductor

of current.

Conductance:
 o Defines the ease with which current flows
through a conducting medium.

o Good conductors:

 Metals (due to large numbers of free

electrons).

 Electrolyte solutions (also rich in free

electrons).

o Insulators
 Materials with fewer free electrons,
offering greater resistance to electron
flow.

 Examples:

o Air

o Wood

o Glass
Factors Affecting Current Flow Through a
Conductor

1. Conduction Characteristics of the Material

o More free electrons → less resistance →

better current flow.

o Example: Blood and nerves have more free

electrons than skin or bone, so current prefers to
travel through them.

2. Cross-Sectional Area of the Path

o Larger cross-sectional area → less

resistance to current flow.

o Example: Large-diameter nerves depolarize

before smaller-diameter nerves.

3. Temperature

o Higher temperature → increased random

movement of free electrons → decreased
resistance to current flow.

o Example: Preheating the treatment area may

increase comfort by reducing resistance and
lowering the need for higher output intensities.
Classification of Electrical Currents

Electrical currents are classified based on their

frequency, which determines which tissues are
stimulated.

1. Low-Frequency Currents (1–1000 Hz)

 Definition: Current where electron flow direction

changes periodically within 1–1000 Hz.

 Effects: Can stimulate both sensory and motor

nerves, with the best effect between 1–100 Hz.

 Examples:

o Faradic Current (FC)

o Diadynamic Current (DD)

o High Voltage Pulsed Stimulation (HVPS)

o Transcutaneous Electrical Nerve

Stimulation (TENS)

o Microcurrent Electrical Stimulation (MES)

2. Medium-Frequency Currents (1 kHz)

 Definition: Current with a frequency of 1 kHz.

  Effects: Can stimulate sensory and motor nerves,
but only after modulation.

 Examples:

o Interferential Current (IF) (modulated

form)

o Russian Current (RC) (interrupted form)

3. High-Frequency Currents (100,000 Hz or more)

 Definition: Currents of 1000,000 Hz (10⁶ Hz) or

more.

 Effects: No effect on sensory or motor nerves.

 Examples:

o Short Wave (SW)

o Microwave (MW)

Specification Parameters of Electrical Currents

Each stimulating current has specific parameters that

determine tissue response.

1. Type
Electrical currents in clinical electrotherapy are
generally classified into:

 Direct Current (DC) (Monophasic):

o Flows in one direction only.

 Alternating Current (AC) (Biphasic):

o Periodically reverses direction.

Direct Current (DC)

 Definition:

o A continuous, uninterrupted, unidirectional

flow of ions or electrons for at least 1 second.

o The direction refers to the flow from positive

to negative or negative to positive.

 Types of DC:

1. Continuous DC ("Galvanic" Current):

 Traditional term for steady,

uninterrupted direct current.

2. Reversed DC:
  The flow stops after 1 second, then
resumes in the opposite direction for at
least 1 second.

 Electrode Polarity:

o One electrode acts as the anode (positive),

and the other as the cathode (negative).

o This remains constant unless the current

direction reverses.

 Clinical Uses:

o Iontophoresis

o Wound care

Alternating Current (AC)

 Definition:

o A continuous, uninterrupted, bidirectional

flow of ions or electrons.

o Must change direction at least once per

second.
 Frequency:

o The rate at which AC switches direction.

o Measured in Hertz (Hz) or cycles per second

(cps).

 Basic Pattern:

o Sine wave (fundamental form of AC).

 Clinical Use:

o Pure sinusoidal AC is rarely used in therapy.

o Modulated forms of AC are more common:

 Burst Modulated AC → Russian Current

 Amplitude Modulated AC →
Interferential Current (IFC)

 Cycle Duration:

o The time required to complete one full cycle.

o Measured from the beginning to the

terminating point on the baseline.
2. Waveforms

Definition:

 The visual representation of current or voltage

over time on a graph.

 Different waveforms produce different

physiological effects, and the body reacts
differently to each.

Types of Waveforms:

1. Sine Wave:

o Offers equal energy levels in positive and

negative phases.

2. Rectangular (Square) Wave:

o Mostly represents direct current (DC).

o Characteristics:

 Rapid, instantaneous rise

 Prolonged duration

 Sharp drop-off

3. Spike Wave:

o Characteristics:
  Rapid rise rate (not instantaneous)

 Immediately drops to zero after reaching

the peak

4. Combined Waves:

o A mixture of rectangular (square) and spike

waves.

5. Twin-Spiked Forms:

o Very short pulse width (microseconds).

o Provides deeper penetration.

o Example: High-voltage galvanic stimulation.

3. Modes of Electrical Currents

Both Direct Current (DC) and Alternating Current

(AC) can be applied in two modes:

1. Continuous (Uninterrupted) Mode

 The current flows without pauses, as previously

discussed.

2. Interrupted (Pulsed) Mode

 Also called pulsatile or interrupted current.

 Definition:
 o Uni- or bidirectional flow of ions or electrons
that stops periodically before the next pulse.

 Terminology:

o Some sources use the terms "Pulsed DC" or

"Pulsed AC", but these terms are not
preferred.

o The correct terms are:

 Monophasic Pulsed Current → One-

directional pulses.

 Biphasic Pulsed Current → Two-

directional pulses.

Pulse and Phase in Electrical Currents

1. Pulse

 Definition: A very brief period of charged

particle movement, followed by a brief cessation
of movement.

2. Phase

 Definition: The flow of current in one direction

for a short period.
  Each phase rises above or below the baseline for
a measurable time.

 Importance:

o The number and type of phases determine

the pulse type and the tissue response.

3. Types of Pulsed Current

 Monophasic: One phase per pulse.

 Biphasic: Two phases per pulse.

 Triphasic: Three phases per pulse.

 Polyphasic: More than three phases per pulse.

Monophasic Pulsed Current (MPC)

 Definition:

o Produced by intermittently interrupting a DC

current source.

o Cannot be used to describe interrupted AC.

 Characteristics:

o One phase per pulse → Unidirectional

current flow.

o Always remains on one side of the baseline.

  Terminology:

o In monophasic current, the terms pulse and

phase are synonymous.

Biphasic Pulsed Currents (BPC)

Definition:

 Consists of two phases, each occurring on

opposite sides of the baseline.

 Produced by intermittently interrupting an AC

current source.

Characteristics:

 Two phases per pulse → Bidirectional current

flow.

Types of Biphasic Pulses:

1. Symmetrical Biphasic Pulses:

o Both phases have equal magnitude,

duration, and shape.
 2. Asymmetrical Biphasic Pulses:

o Each phase has a different shape.

Symmetry of Phases in Biphasic Pulsed Current

1. Symmetrical Biphasic Pulses

 Both phases have equal magnitude, duration,

and shape.

 Most comfortable due to lower charges per

phase.

2. Asymmetrical Biphasic Pulses

 Balanced Asymmetrical:

o Equal charge (area) under the curve in both

negative and positive directions.

 Unbalanced Asymmetrical:

o Unequal charge (area) under the curve in

both negative and positive directions.
Key Differences Between Biphasic and Monophasic
Currents:

 Monophasic Current:

o Can cause chemical changes due to its

unidirectional flow.

o Chemical effects usually occur when the

stimulus is continuous and applied for a long
duration.

 Biphasic Current:

o Less likely to cause chemical changes because

charges balance out over time.

Terms Describing Pulsed Currents

1. Current Amplitude

 Definition:

o The maximum height of the wave above or

below the baseline (peak amplitude).

 Peak-to-Peak Amplitude:

o The total distance from the positive peak to

the negative peak.
 o Note: Monophasic waves do not have a
peak-to-peak value.

 Significance:

o Reflects current intensity.

o The highest point of each phase represents the

maximum amplitude.

 Units of Measurement:

o Amperes (A), microamps (µA), or milliamps

(mA).

 Synonyms:

o Voltage and Current Intensity.

Voltage and Current Amplitude Considerations

 Voltage Measurement:

o Measured in volts (V), microvolts (µV), or

millivolts (mV).

o Higher amplitude → greater peak voltage or

intensity.

 Peak Amplitude vs. Average Current:

 o Peak amplitude is not the same as total
current delivered per unit of time (average
current).

o Long pulse duration + high average current

→ increased pain sensation.

 Total Current Production:

o Short-duration pulses → low total current

due to long interpulse intervals (zero
amplitude between pulses).

o Total current can be increased by:

1. Increasing pulse duration.

2. Increasing pulse frequency.

3. A combination of both.

Pulse Charge & Current Density

1. Pulse Charge

 Definition: Total electricity delivered per pulse

(measured in coulombs or microcoulombs).

 Monophasic Current:

o Phase charge = Pulse charge (always

greater than zero).
  Biphasic Current:

o Pulse charge = Sum of phase charges.

o Symmetric pulses → Net pulse charge = 0.

o Asymmetric pulses → Net pulse charge > 0.

2. Current Density

 Definition: Amount of current per unit area

(volume of current in tissues).

 Depends on:

1. Electrode placement (distance between

electrodes).

2. Electrode size.

Effects of Electrode Placement & Size on Current

Density

1. Electrode Placement:

 Close together → Higher current density

superficially.

 Farther apart → Higher current density in

deeper tissues (affecting nerves & muscles).
2. Electrode Size:

 Smaller electrode → Higher current density

beneath it.

 Larger electrode → Current spread over a

larger area, lowering current density.

3. Effect on Sensation:

 Increased current density → Stronger

perception of the stimulus.

Electrode Application in Clinical Use

1. Electrode Positioning for Maximum Effect:

 Small (active) electrode → Placed near the nerve

or muscle motor point → High current density →
Stronger effect.

 Large (dispersive) electrode → Placed away from

the treatment area → Lower current density →
Disperses current over a larger area.

2. Key Factors Controlled by the Therapist:

  Electrode size & placement significantly
influence treatment effectiveness.

 High current density near the target neural

structure ensures successful stimulation with
minimal current.

 Incorrect electrode placement is a major reason

for poor therapy outcomes.

Pulse Duration in Electrical Stimulation

1. Definitions:

 Pulse Duration (Pulse Width):

o Time from the beginning of a pulse to its return

to zero.

o Includes all phases in a pulse.

o Expressed in seconds (s), milliseconds (ms),

or microseconds (µs).

 Phase Duration:

o Time for a single phase to complete its shape.

 Interpulse Interval:
 o Time between the end of one pulse and the
start of the next.

 Intrapulse Interval (Interphase Interval):

o Break within a single pulse before the next

phase starts.

2. Clinical Importance:

 Short pulse durations → Stimulate sensory

nerves.

 Longer pulse durations → Stimulate motor and

pain fibers.

3. PULSE FREQUENCY:

 The number of electrical pulses that occur in 1

second.

 Expressed as pulses per second (pps) or Hertz

(Hz).

 Inverse relationship between pulse frequency and

tissue resistance:

o A current with lower pulse frequency (e.g.,

10 pps) meets more resistance.
 o A current with higher pulse frequency (e.g.,
1000 pps) meets less resistance and requires
lower intensity.

Effects of Frequency:

It affects:

1. Type of muscle contraction.

2. Mechanism of pain modulation.

PULSE RATE OF RISE AND DECAY TIMES:

 Rise time: How quickly the pulse reaches

maximum amplitude in each phase.

 Decay time: How quickly the pulse returns to zero

from peak amplitude.

Physiological Importance:

 Accommodation phenomenon: If a fiber is

subjected to constant depolarization, it becomes
unexcitable at the same intensity.

 Rate of rise and decay:

 o Usually very short (nanoseconds to
milliseconds).

o Affects nervous tissue excitability.

o Faster rise time → Greater ability to excite

nerves.

Waveform Characteristics:

 Sine wave: Gradual rise and fall.

 Rectangular wave: Instant rise, plateau, abrupt

drop.

 Spiked wave: Rapid rise, then immediate drop.

Waveform Characteristics and Nervous Tissue

Excitability:

1. Sine Wave:

o Gradual increase and decrease in amplitude.

o Found in alternating, direct, and pulsatile

currents.

2. Rectangular (Square) Wave:

o Instantaneous rise to maximum amplitude.

o Plateaus for a period, then abruptly falls off.

 3. Spiked Wave:

o Rapid increase in amplitude.

o Immediately drops after reaching peak.

Relation to Nervous Tissue Excitability:

 Faster rise time → Greater ability to excite

nervous tissue.

 Spiked and rectangular waves excite nerves

more efficiently than sine waves.

Duty Cycle in Electrical Stimulation:

1. Definition:

o The ratio of ON time (current flowing) to

total cycle time (ON + OFF time).

o Expressed as a percentage or ratio.

2. Formula:

Duty Cycle = (On Time ∕ (On Time + Off Time)) ×

100

3. Example Calculations:

o 10s ON, 30s OFF → Duty Cycle = 25%.

 o 5s ON, 15s OFF → Duty Cycle = 25% (different
pattern, same ratio).

4. Clinical Importance:

o Prevents muscle fatigue in neuromuscular

stimulation.

o Stimulation starts at 25% duty cycle and

increases as the condition improves.

POLARITY

Definition:

Polarity in electrical stimulation refers to the difference

in electron levels between electrodes.

Electrodes:

 Negative Electrode (Cathode): Has more

electrons.

 Positive Electrode (Anode): Has fewer electrons.

Effects:

 The negative electrode (cathode) attracts

positive ions.

 The positive electrode (anode) attracts negative

ions and electrons.
AC Wave Behavior:

 In Alternating Current (AC), electrodes switch

polarity with each cycle.

POLARITY IN DIRECT CURRENT (DC) GENERATORS

Electrode Designation:

 In DC generators, the therapist can assign:

o Negative electrode (-) (Cathode)

o Positive electrode (+) (Anode)

 These electrodes maintain their polarity

throughout treatment.

Polar Effects:

Polarity influences three key characteristics:

1. Chemical Effects – Ion migration occurs, leading to

chemical reactions at the electrode sites.

2. Ease of Excitation – The negative electrode

(cathode) lowers the threshold for nerve activation.
 3. Direction of Current Flow – Current moves from
the negative electrode (cathode) to the positive
electrode (anode).

Current Modulation

Definition:
Modulation refers to alterations in current
parameters to reduce or minimize accommodation
(adaptation of nerves to electrical stimulation).

Types of Modulation:

1. Amplitude Modulation:

o Variations in the peak amplitude of a series of

pulses.

2. Pulse or Phase Duration Modulation:

o Regular changes in pulse duration over time.

3. Frequency Modulation:

o Cyclic variations in the number of pulses per

unit time.
 4. Surged (Ramped) Modulation:

o Gradual increase (ramp-up) or decrease

(ramp-down) in:

 Pulse amplitude

 Pulse duration

 Both amplitude & duration over time.

Burst Modulation

Definition:

 Burst modulation refers to the generation of two

or more consecutive pulses, separated from the
next series of pulses by an interburst interval.

Key Terms:

1. Burst:

o A group of two or more consecutive pulses.

2. Interburst Interval:

o The time between bursts.

3. Burst Frequency:

o The rate at which bursts are generated.

4. Carrier Frequency:
 o The frequency of the underlying AC waveform
in the burst.

Pulse Train

Definition:

 A pulse train consists of individual patterns of

waveforms, duration, and/or frequency that are
linked together.

 These linked patterns repeat at regular intervals.