Application technique

Applying Electrical Stimulation

 Electrical Stimulation: Applying stimulation

transcutaneous throughout the electrode that placed
directly on the skin.
 Stimulators can be mains or battery powered. Each one

has its pros & cons.

 Also stimulators can be constant voltage or constant

currents ,which depends on machine design. Each one

had its own pros and cons, however, therapists must
understand the implications of each type.
 For safety reasons, constant voltage stimulations are

preferred,
 Constant voltage means that the voltage output level set
by the therapist will remain the same, if the impedance
of the tissue or of the tissue-electrode interface or both
are changed, the current will also change but the voltage
will remain constant.
 The clinical advantage (pros) of a constant-voltage
stimulator is the automatic reduction of current when
electrode size is reduced or if electrode contact with the
skin become loose.
 The disadvantage (cons) of the constant-current is
apparent when electrode size or pressure with the
skin or both is reduced and lead to a sudden
increase of current concentrations. The result is a
sudden discomfort of the stimulation and in
extreme cases, electrical burns.
Stimulating Different
Nerves
 The amplitude (intensity) of current needed to
stimulate a nerve fiber is inversely proportional to
its diameter. The larger fibers have a lower
electrical resistance.
 The difference in sensitivity between motor and

sensory fibers is due to their different depth;

sensory nerves in the skin receive higher current
density than deep motor fibers.
Stimulating Different
Nerves

 From strength
duration curve
you can see
that it easy to
excite sensory
and motor
nerves without
eliciting pain
Patient position
Patient positioning is dictated by:
 area to be treated,
 goal(s) of treatment
 device used. Primary to

These three issues are patient comfort and

modesty.
Electrodes
The appropriate selection of electrodes for
transcutaneous ES is important for many reason:
 Electrodes provides not just a means of applying

currents to the body but also a means of distributing it.

 The type of electrodes , size and location on the body

are three issues to be considered.

1. Material (Type ):
carbon silicone electrodes are recommended but will
develop hot spots with repeated use ..
Self adhesive are also recommended but its only can
be used for the same patient .
Electrode type

1.Self adhesive 2. Carbon silicone electrodes

Other electrode types

4. conductive fabric electrode

3. Sensitive skin electrodes (made from a conductive
(made with a blue gel and threading, such as silver, woven
have less adhesive into another fabric in the
and more water in the gel). shape of a garment such as a
glove, sock, or sleeve Garment)
Electrode
2. Size:
based on size of target area
current density is important. The smaller the electrode
size the greater the density.
3. Location :
Either on muscle fiber or nerve .
Electrode placement
1. Electrodes should not be placed directly
over bony prominences because:
 poor adhesion of electrodes
 Increase the risk of discomfort
 Increase the risk of burns
 less likely to produce therapeutic benefits.
Electrode placement
 The distance or spacing between electrodes
affects the depth and course of the current.
The closer together electrodes are
configured, the more superficially the
current travels, and conversely, the greater
the distance between them, the deeper the
current travels
PARAMETERS FOR
ELECTRICAL STIMULATION
OF CONTRACTION BY
INNERVATED MUSCLES
PARAMETERS FOR ELECTRICAL STIMULATION
OF CONTRACTION BY INNERVATED MUSCLES
Neuromuscular Electrical Stimulation
(NMES).
Waveform :
 A pulsed biphasic waveform, or Russian

protocol, should be used when electrical

stimulation is used to produce muscle
contractions.
 Russian protocol, which is available on

select units, may produce greater and

faster strength gains.
 Russian protocol stimulation is provided
with a medium-frequency alternating
current with a frequency of 2500 Hz
delivered in 50 bursts per second.
 The burst has a duration of 10 milliseconds,

as does the interburst interval.

 Russian protocol was first described by Kots,

who used this waveform to train Russian

Olympic athletes.
PARAMETERS FOR ELECTRICAL
STIMULATION OF CONTRACTION BY
INNERVATED MUSCLES
Electrode placement
 Two electrodes are

aligned parallel to the

direction of the
muscle fibers,
allowing the current
to travel parallel to
the direction of the
muscle fibers
 The motor point is the place where an electrical
stimulus will produce the greatest contraction
with the least amount of electricity.
 Motor points: it is the area of skin over the
place where the motor nerve enters the muscle.
 Charts of motor points are available; however,
because most motor points are over the middle
of the muscle belly, it is generally easy and
effective to place electrodes over the middle of
the muscle belly.
PARAMETERS FOR ELECTRICAL
STIMULATION OF CONTRACTION BY
INNERVATED MUSCLES
Pulse duration:
 When electrical stimulation is used to

produce a muscle contraction in an

innervated muscle, the pulse duration
should be between 150 and 350 ms to
stimulate motor nerves.
 As the pulse duration is shortened, higher

amplitude current will be needed to achieve

the same strength of contraction produced
by a longer pulse duration.
PARAMETERS FOR ELECTRICAL
STIMULATION OF CONTRACTION BY
INNERVATED MUSCLES
FREQUENCY
 Pulse frequency determines the type of response or muscle
contraction that electrical stimulation will produce.
 each pulse will produce a separate muscle twitch contraction.
 As the frequency increases, the twitches will occur more
closely together.
 This
 Increasing the frequency beyond 50 to 80 pps may produce
greater muscle strengthening but will also result in more rapid
fatigue during repeated
 A lower frequency of 20 to 30 pps may be better tolerated
and more effective when smaller muscles such as the muscles
of the face and distal upper extremities in adults and all
muscles in young children are stimulated.
PARAMETERS FOR ELECTRICAL
STIMULATION OF CONTRACTION BY
INNERVATED MUSCLES
On and off time
 When electrical stimulation is used for

muscle strengthening on:off ratio of 1:5.

 The long off time is required to minimize

muscle fatigue.
 When the patient gets stronger, the on:off

ratio may be decreased to 1:4, or even 1:3.

 When the goal of electrical stimulation is to
relieve a muscle spasm, the on:off ratio
is set at 1:1.Times set between 2 and 5
seconds, to produce muscle fatigue and
relax the spasm.
 When treatment is intended to pump out

edema, the on:off ratio is also set at 1:1,

with both on and off times set between 2
and 5 seconds.
PARAMETERS FOR ELECTRICAL
STIMULATION OF CONTRACTION BY
INNERVATED MUSCLES
RAMP TIME
 A ramp time may be needed when a muscle

contraction is stimulated.
 The ramp time allows for a gradual increase

and decrease of force rather than a sudden

increase when switching from off time to on
time, and a sudden decrease when
switching from on time to off time.
PARAMETERS FOR ELECTRICAL
STIMULATION OF CONTRACTION BY
INNERVATED MUSCLES
Amplitudes
 Motor level visible muscle contraction

Treatment time
 Used for muscle strengthening, it is generally

recommended that treatment last long enough to

allow for 10 to 20 contractions. This will usually take
about 10 minutes.
 When electrical stimulation is used for muscle re-

education, treatment time will vary based on the

functional activity being addressed.
 No longer than 20 minutes at a single session.
Review
1. Electrical stimulation to produce contractions of
innervated muscles is called neuromuscular
electrical stimulation (NMES).
2. Muscle contractions produced by electrically
stimulated action potentials in motor nerves can
strengthen muscles, increase muscle endurance,
improve function, assist with joint positioning,
decrease spasticity, increase circulation, and control
pain.
3. Electrically stimulated contractions preferentially
recruit type II muscle fibers and those closest to the
electrode. These contractions are more fatiguing
than voluntary contractions.
4. Electrical stimulation strengthens muscles
according to overload and specificity
principles.
5. NMES can reduce the weakness associated
with orthopedic conditions and surgeries such
as ACL repair, total knee arthroplasty,
osteoarthritis, patellofemoral syndrome, and
shoulder subluxation.
6. NMES has been used to maintain or regain
muscle strength and function in people with
neurological conditions such as spinal cord
injury, stroke, and multiple sclerosis.
7. NMES has been used in a wide variety of
conditions where muscle weakness causes
impairment; new uses continue to be studied.
PARAMETERS FOR ELECTRICAL
STIMULATION OF CONTRACTION BY
DENERVARED MUSCLES
Electrical Muscle Stimulation (EMS).
 If the electrical current lasts longer than 10
milliseconds, the denervated muscle will
contract. This is called electrical muscle
stimulation (EMS).
 Direct current (DC) is applied for a number of
seconds to produce contractions in denervated
muscle.
 To produce a graded contraction in a denervated
muscle, the current amplitude can be gradually
increased to reach full amplitude over a number
of seconds.
 Although DC electrical stimulation has
traditionally been used for treatment of
Bell’s palsy (facial paralysis resulting from
damage to the seventh cranial nerve),
evidence indicates that this treatment is no
more effective than placebo.
 some studies have shown improved clinical

recovery in patients with chronic facial palsy

in response to long-term sensory level
electrical stimulation
 PARAMETERS FOR
ELECTRICAL
STIMULATION FOR PAIN
CONTROL
Waveform
1. A pulsed biphasic waveform or
interferential current, which is
produced by two interfering alternating
currents, are the waveforms most
commonly used for pain control.
2. pulsed biphasic current or TENS also
be effective and used to reduce pain.
3. Pulsed monophasic currents, such as
high-voltage pulsed current, can also
be used to reduce pain.
Which current I should
select???
A pulsed biphasic or monophasic
waveform requires only two
electrodes and therefore is quicker to
set up than interferential current, but
interferential current may be more
comfortable, may affect a larger and
deeper area, and may provide a
longer-lasting effect.
Electrode placement
1. Around the painful area is most common.
2. Over trigger points or acupuncture points,
which generally are areas of decreased skin
resistance, has also been reported to be
effective.
3. When the electrodes cannot be placed near or
over the painful area, for example, if the area
is in a cast or local application of the
electrodes is not tolerated, the electrodes can
be placed proximal to the site of pain along the
pathway of the sensory nerves supplying the
area.
Electrode placement
 When pulsed currents
(Interferential) are used, the
electrodes can be placed so
that the two currents intersect,
allowing the current to cross at
the area of pain or they may
be placed in parallel, either
horizontally or vertically. When
two pulsed currents are used,
they are of the same
 For all applications, the
electrodes should be at least 1
inch apart.
Pulse Duration
 High rate or conventional TENS, the
pulse duration should be between 50 and
80 ms to depolarize only the A-beta sensory
nerves.
 Low-rate TENS is applied, the pulse

duration should be between 200 and 300

ms to also depolarize the motor nerves and
possibly the A-delta nerves.
Frequency
 Selection of pulse frequency for pain control
depends on the desired mode—
conventional, low-rate, or burst.
ON:OFF TIME
 When applied for pain control, electrical
stimulation is delivered continuously throughout
treatment time with no “off” time.
 This is necessary because according to the
gate control theory, the current blocks the
pain only when it is stimulating A-beta nerve
fibers. During any “off” time, no A-beta nerves
would be stimulated, and no pain reduction
would be felt. Similarly, endogenous opioid
release is stimulated when low-rate TENS is on,
not during any “off” time.
Amplitude
 For conventional TENS gentle
sensation that is perceived as tingling or
vibration.
 For low-rate and burst TENS muscle
contraction that can be seen or palpated by
the clinician.
Treatment time
 20 to 30 minutes.
 Low rate and burst mode TENS should not

be used for longer periods because the

muscle contractions they produce can
cause delayed-onset muscle soreness.
Delayed-onset muscle
soreness.
 Delayed onset muscle soreness (DOMS)
is the pain and stiffness felt
in muscles several hours to days after
unaccustomed or strenuous exercise.
 The soreness is felt most strongly 24 to 72

hours after the exercise.

 After such exercise, the muscle adapts

rapidly to prevent muscle damage, and

thereby soreness, if the exercise is
repeated.
Review
1. Electrically stimulated action potentials in sensory or
motor nerves can control pain.
2. Transcutaneous electrical nerve stimulation (TENS) is the
use of transcutaneous electrical stimulation to modulate
pain.
3. Three types of TENS are available: conventional, low rate,
and burst mode.
4. Conventional (high-rate) TENS uses short-duration, high-
frequency pulses to reduce the sensation of pain by the
gate control theory.
5. Low-rate (acupuncture-like) TENS stimulates the release of
endogenous opioids to mediate pain.
6. Burst mode TENS has a mechanism of action similar to
that of low-rate TENS, but the current is delivered in bursts
of pulses.
7. A pulsed current or an interferential current can be used
for TENS ADDITIONAL RESOURCES
PARAMETERS FOR
ELECTRICAL
STIMULATION TO
PROMOTE WOUND
HEALING
Indication for ES in wound
healing
1. Pressure ulcer
2. Diabetic ulcer
3. Venous ulcer
4. Traumatic wound
5. Surgical wound
6. Ischemic ulcer
7. Burn wound
8. Donor sites
9. Wound flaps
Application technique
Waveform:
 HVPC, a monophasic pulsed current, was

used in most studies showing benefit for

this application.
 Low-intensity DC (LIDC)
 pulsed biphasic (TENS)
 AC waveforms have also been found to be

effective in a few studies.

HVPC
 Application of high
voltage low amperage
current, to a specific
region of the body.
HVPC characteristic:
 Very short pulse duration
 Voltage greater than 100

volts
 Frequency range form 0-

150pps
 Unique twin peak

monophasic waveform
Electrode Placement
Electrodes may be placed in or around
the wound.
 One treatment electrode is used when the

treatment electrode is placed directly in the

wound.
 Two or more treatment electrodes may be

used when stimulation is applied to the area

around the wound.
Electrode Placement
 If stimulation is applied
directly to the wound,
the electrode should
be made to fit the
wound.
 This type of electrode
is made by first placing
saline-soaked gauze
directly in the wound
and then covering this
with a single-use
disposable electrode.
Electrode Placement
 If stimulation is
applied to the
intact tissue
around the wound,
the usual
commercially
available self-
adhesive
electrodes are
recommended.
Special consideration
 Dispersive electrode, of opposite polarity
to the treatment electrode, should be
placed on intact skin close to the wound
site.
 The dispersive electrode completes the

electrical current circuit but is not

considered a “treating” electrode.
 The dispersive electrode should be placed

several inches away from the wound site.

Polarity
 The polarity of the electrode on or nearest
to the wound is selected according to the
types of cells required to advance a
particular stage of wound healing and the
presence or absence of infection or
inflammation in the wound. Negative
polarity is generally used during the early
inflammatory stage of healing, whereas
positive polarity is used later to facilitate
epithelial cell migration across the wound
bed.
Pulse Duration
The pulse duration recommended when
HVPC is used to promote wound healing is
between 40 and 100 ms.
 This parameter is generally preset in the

device by the manufacturer and cannot be

changed by the clinician.
Frequency
 Pulse frequency for promoting tissue

healing should be in the range of 60 to 125

pps.
On:Off Time
 Electrical stimulation is delivered

continuously throughout treatment time

when applied for tissue healing.
 This maximizes the amount of charge

delivered and thus the attraction of charged

particles.
Current Amplitude
 The current amplitude should be sufficient
to produce a comfortable sensation
without a motor response.
Treatment Time
 At this time, most studies recommend
treating for at least 5 days each week.
 Treatment lasting 45 to 60 minutes.
Application technique
for iontophorosis
Iontophososis
 Iontophoresis is a method of delivering
medication ions through the intact skin. It is an
alternative to injection or oral delivery.

 Iontophoresis with dexamethasone is currently

a first line defense for localized inflammation.

 With continued education in the field,

iontophoresis will become a primary tool for other
common conditions.
Definition
 A process in which a continuous direct current is
used to drive electrically charged molecules or
atoms (ions) into the tissues

 Iontophoresis delivers high concentrates of polar

substances, or medicinal agents, into the skin,
but to questionable depths

 The amount of medicine transferred through the

skin is directly related to the duration of
treatment, current density, and concentration of
the ions in the solution
Iontophoresis
Duration of Treatment :
Based on intensity desired usually every other day
for 3 weeks
Indications
Acute or Chronic Inflam
Arthritis
Myositis
Myofacial Pain Syndromes
Invasive method for delivering drugs
Iontophososis
Contraindications
Hypersensitivity to electrical currents
Contraindications to meds.
Pain of unknown origin
Side effect:
 Burn
 alkaline reaction (discomfort, skin irritation, or

chemical burns)
Iontophososis
 Iontophoresis is the use of low-amplitude
DC to facilitate transdermal drug delivery.
 The use of iontophoresis was first reported

in the early 1900s.

 Iontophoresis is based on the principle that

like charges repel, and that therefore a fixed

charge electrode on the skin can promote
the movement of charged ions of a drug
through the skin by “pushing” them away
 To reduce the risk of skin
irritation, optimize comfort,
and provide prolonged drug
delivery, iontophoresis
delivery systems that have
low voltage output and
apply an extremely low
current for a much longer
period of time have
recently been developed.
These devices have a
battery within the
electrodes and deliver
between 0.1 and 0.3 mA for
a period of 1 to 24 hours,
delivering a total dose of
approximately 40 to 80 mA-
min .
Ion Transport
 Iontophoresis is limited to medications/ionic
solutions with the following profile:
 The ions must be charged.
 Foe example: Dexamethasone and acetic acid are
both negative.
 Relatively small ions
 They must have a molecular weight less than 8000
daltons.
 Must be in a solution- no creams or suspensions.
 The application will not yield much if any systemic
effects. The ions must be able to be effective in a
small target area.
Iontophoresis: Advantages over
an Injection
 There is no trauma to the skin from a needle
puncture which decreases the likelihood of
infection.

 Less medication/ion gets into blood supply

(decreased systemic effect).

 It is relatively painless.
More
 Permitsthe use of a drug with a short
biological half life because

(1) the drug is delivered directly to the target area

without the need to circulate and recirculate in
the blood

(2) the drug is delivered directly into the

bloodstream without delays due to absorption
through the GI tract
PARAMETERS FOR
IONTOPHORESIS
Electrode Placement and Size.
 Delivery Electrode (drug electrode)
placed over target tissue
 Active electrode (dispersive electrode)
place 4-6 inches from drug electrode
Electrode Placement and Size.
 For iontophoresis, the drug delivery electrode is
placed over the area of pathology.
 When a low-voltage patch electrode is used, both
negative and positive polarity electrodes are within
the same patch.
 When an iontophoresis unit with wired electrodes is
used, the dispersive or return electrode is placed a
few inches away from the treatment electrode at a
site of convenience over a large muscle belly.
 The electrode should be large enough that the
current density does not exceed 0.5 mA/cm2 when
the cathode is used as the delivery electrode, and
1.0 mA/cm2 when the anode
 is used
Current Amplitude.
 For iontophoresis, the amplitude should be
determined by patient comfort and should
be no greater than 4 mA.
Treatment time
 Total treatment dose of 40 to 80 mA-min
Review
1. The ionic effects of electrical currents can be
used to facilitate tissue healing by attracting
or repelling cells that carry a charge—a
process called galvanotaxis.
2. Electrical stimulation applied to chronic
wounds may accelerate healing by attracting
appropriate cell types to the injured area and
increasing collagen production by fibroblasts.
3. Iontophoresis is the delivery of drugs
through the skin facilitated by an electrical
current of the same polarity as the drug.