SUBJECT AND TASKS OF PHYSIOTHERAPY. GALVANIZING AND ELECTROPHORESIS. ELECTRODREAM, DIADYNAMIC THERAPY, ELECTROSTIMULATION. AMPLIPULSTHERAPY.
I the general representations about physiotherapy and spa-treatment.
The knowledge of mechanisms of influence of the physical factors, precise representation of features of their influence on physiological and pathological processes in an organism is a necessary condition of their rational use for treatment and prophylaxis of diseases.
Scientific researches of medical application of physical factors specify necessity of correct batching of the last, taking into account an initial condition of an organism, its functionalities and reactions answers. Physical methods of treatment are not opposed other medical agents, and used in various combinations to them.
Under influence of physical factors the general background of vital activity of an organism, a trophicity of tissues is improved, a general stimulation of an organism, anti-inflammatory and desensitizing action, normalization of a vegetative regulation, optimization of neurodinamics are initiated.
Physical factors were used with the medical purpose in an extreme antiquity (Hippocrat, Abu Ali ibn Sina). Home scientists always paid attention to their big role in treatment and prophylaxis of diseases. At the end of XVIII century in clinics of the Moscow university it was rather widely applied electrotherapy. In 1825 Nicitin has described usage with the medical purpose the natural and artiticialy prepared mineral waters. M.J.Mudrov and F.I. Inozemcev in II half of the XIX century successfully practised a hydrotherapy. Outstanding Moscow clinician G.A.Zahar’in recommended using of of the balneal and physiotherapeutic treatment, massage and gymnastics in profession of a physician.
The big role in development of a physiotherapy belongs to Institute of physical methods of treatment in Sevastopol which headed by A.J.Shcherbak. The institute developed a reflex direction in studying physiological mechanisms of influence on an organism of physical agents. Proceeding from A.J.Shcherbak’s ideas original medical techniques (a galvanic collar on Shcherbak, a technique of ionic reflexes etc.), till now not lost the value were developed. Recently, at studying action of physical factors, are used as advanced achievements of physiology (G.Sel’e’s critically rethought theory, the doctrine about a reticular formation) and biology (molecular biology), and achievement of biophysics, electronics (creation of the devices regulating key parameters of the functioning of the blood-circulatorium system, automatics of impellent pulses in the paralysed muscles etc.).
Physiotherapy – the medical science studying mechanisms of physiological and medical action of natural and preformed physical medical means for the persons and animals.
Physiotherapeutic prophylaxis – preventive, improving application of physical factors within the framework of initial, secondary and tertiary preventive maintenance. For initial preventive maintenance water, air, solar and ultra-violet rays, the artificial aero-ions, dosed out physical loadings are used basically. For tertiary – may apply all arsenal of physical medical means.
Spa-treatment science-a science, about preventive and medical application of natural physical medical means – mineral waters, dirties, curative climates, ozokerite, naphtalanum etc., and also about the organization of a resort affair.
The modern physiotherapy has a huge arsenal of equipment rooms and hardware of treatment, devices of pulse currents, microwaves, magnetic fields, a laser and ultra-violet irradiation, ultrasound vibrating, tens designs of baths. douches and etc. Have received the big development of physiopuncture (laser, electric, thermal, magnetic etc.), physiopharmacotherapy (electrophoresis and phonophoresis of medicinal substances, medicinal baths, inhalations, massage).
Physiotherapeutic studies or branches are available almost in each medical establishment. They may be specialized, intended for one structure of patients, or versatile, usually, in large hospitals and polyclinics. Studies of physiotherapy and halls of physiotherapy exercises make a basis of divisions of regenerative treatment, branches, polyclinics, hospitals.
The sanatorium esteblishtments also build their work on the basis of physiotherapy and therapeutic exercises. The structure of physiotherapeutic departments usually includes studies (halls) of electric-,light-, hydro-, warm and mechanical therapy.
II. Classification of physical medical means and methods
А. Electric currents and methods of their application
1. Electric currets of a low voltage:
-galvanic currents and medicamental electrophoreses;
-impulse currents of constant and variable directions(diadynamic therapy,amplipulse therapy,interference therapy,electrosleep,electrostimul therapy,ultratonetherapy,fluctuorisation,electropuncture);
2. Electric currets of a high voltage:
-local darsonvalization;
– a diathermy;Franclinization;
3.Electric and magnetic fields:
contant electric field of a high voltage;
constant magnettic field;
– variable magnetic field of low frequency;
– variable magnetic field of high frequency;
– variable electric field of ultrahigh frequency(UHF);
– variable electric field of super high frequency(microwave therapy-MWT).
4. Light radiation:
-Seen rays;
-Infra-red radiation;
-Ultra-violet rays;
–Laserotherapy ; Monochromatic(coherent) radiation.
5. Mechanical fluctuations :
-infrasound(vibration);
-Ultrasound;
-Massage; manual therapy;
–Phonotherapy.
6. artificial created of air medium:
–Aeroions,hydroaeroions;
–Aerosols,electrical aerosols.
7. Variable air pressure(barotherapy).
8. Radioactive factors:
-Radon;
-L-applicators.
9. Balneological factors:
-Fresh water;
-Natural and artificial mineral waters
10. The factors of thermal therapy;
–Muds;Paraffin;
–Ozocerite;
–Naphthalanums;
–Cley;
-Send.
III. The general principles of physiotherapy
1. A principle of a generality of mechanisms of actioatural and preformed physical medical means solar and artificial light, the natural and artificial microwaves natural and artificial magnets, the natural both artificial activated fresh and mineral waters and etc.
Its many methods are not especially physical: electro-,phonophoreses, mineral waters, medical dirties, medicines, a drink of mineral waters, hydrosulphuric, carbonic and other baths, medicinal inhalations and etc.
4 Principle of many-sided nature of physical therapy; it is applied in all areas of medicine, including a tuberculosis and oncology. Physical factors can be applied at all stages of diseases – in acute, subacute, the chronic and rehabilitation periods only correct technique and a dosage is important.
5 Reflex principle Much in physiotherapy is connected to the reflex chain reactions developing in an organism, in tissues and bodies in reply to application of physical factor. Physical procedures frequently are a push (pushes) influencing the mechanism of sanogenesis. Certainly, the leading part is played here by the central and vegetative nervous system. Here it is possible to attribute(relate) and the resonant phenomena shown at rhythmic influence.
6. The principle of dialectic unity of the specific and nonspecific parties(sides) of the mechanism of action of physical medical means Each physical factor having independent value in medicine, has any specificity of the mechanism of the action, allowing to give it preference at this or that form of a pathology, differently it is superseded by another At the same time, many factors have the nonspecific thermal and mechanical effects growing at amplification(strengthening) of a doze (power of influence) and overlapping the specific sides of the mechanism of action.
7 Principle of primary efficiency astable, including pulse physical influences From physiology and electrophysiology it is known, that nervous and other systems of an organism rather quickly adapt for stable, monotonous, especially weak influences – are removed and responses and accordingly in physiotherapy – medical effect disappear.
8 Principle of adequate use various on force of physical influences very weak (information), weak, average force and strong. This principle is excellent proved in fundamental researches L.Harcavy, Е. Кvakyna and M.Ukolova (1972-1976). It underlies a practical principle of selection of optimum dosages on force. All enormous world experience of physiotherapy testifies to expediency of differential uses of influences of different force on a condition, age, the patient and features of development of disease.
9 Principle of repeatability of application physical (physical and chemical) preventive and medical influences. This principle plays a special role in physioprophylaxis where maintenance of a level of health demands regular constant (or as periodic hens Owls) applications of cool and cold waters, air baths, ultra-violet irradiations and etc.
10. The principle of compatibility of one physical medical factors with others, with medicamentous and not medicamentous means, psycho-, кinetic -, herbal and pharmacotherapy This principle underlies practical efficiency of complex therapy
IV. Mechanisms of physiological and medical action of physical factors
Reactions of an organism to physiotherapeutic influences may be mainly local, on a distance from a place of influence (reflex within the framework of segments and etc.) and general.
Allocate the time physiotherapeutic reactions developing more often after first 2-3 procedures and rather evanescent – in 2-4 days after occurrence (reaction of adaptation), neurotic, vegetovascular, dermato–allergic, muscular, dispeptic, temperature, as an aggravation of disease, hematological and biochemical they may be subclinical, easy, average weight and heavy.
At overwhelming majority of patients first two variants Expressiveness and character of reactions are observed depend on an initial condition of an organism and its bodies, from a stage of disease, from a place and the area of influence (biologically active points, sites and zones), from its intensity and duration, from specific properties of physical factors, from a rhythm of alternation, repeatability of procedures That may occur in tissues at physical procedures: change (increase or downturn) blood circulation, permeability of tissues, intensity of a metabolism, a muscular tone, excitability of nervous elements, intensity of formation of biologically active substances. Physical factors may render antiallegic, antiseptic action they may destroy stones in kidneys, in bilious and uric bubbles liquidate fine papillomas, hematomas, warts etc. Physical factors may change excitability of structures head and a spinal cord (for example, in electrodream) to influence secretion желез internal secretion, changing as a whole ability to live of many systems of an organism.
At some pathological processes there is enough one procedure for reception of medical effect (a hot bath at cholelithiasis and nephrolithiasis, hyperthermal influence (sauna) at acute respiratory diseases, to manipulation on a backbone at painful syndromes and etc.).
However in the regenerative period after diseases and traumas, at a chronic pathology one course of treatment consisting of many procedures In these cases treatment frequently is frequently insufficient happens complex, switching 2-3 different influences: physical procedures with therapeutic exercises, massage, medicines and psychotherapy may be combined only.
Physical medical factors may be applied in calculation on especially local medical effect treatment of ulcers, wounds, local inflammatory and other processes
Physical treatment factors may be appointed locally to healthy tissues with the purpose of reception of reflex curative effects (hot compress on the left hand improves the coronary blood circulation and may weaken or liquidate an attack of a stenocardia.
Procedures of physiotherapy may be addressed the central nervous system, head or to a spinal cord (electrodream, influence by microwaves or Electric Field UHF and etc.) in calculation on somatic medical effect In particular, electrodream is shown at a bronchial asthma, a stomach ulcer of a stomach, obliterating endarterites, hypertonic and ischemic disease of heart etc.
Methods of physical medical influence on glands of internal secretion: adrenal glands, thyroid, sexual are developed and applied etc. One of examples: at system chronic inflammatory processes by microwaves adrenal glands are irradiated.
Ultra-violet rays and lasers apply to direct influence on blood, in particular, at some forms of Ischemic disease of heart, the Ultra-violet-irradiation of blood carries out and at septic conditions.
Besides all specified, there are many genera l(common) physiotherapeutic influences the general (common) water and air baths, general Franclinization, d’Arsonvalization, galvanizing etc.
V. The main principles of application of physical educational and preventive means
Principle of continuity of application of physical medical means
Before assignment of physical factors the doctor precisely is obliged to imagine, what medical actions were appointed to the patient earlier as it transferred what the result of treatment was them.
Appointing electroprocedures, it is important to know their bearableness the patient Quite often there is an intolerance of an electric current.
The principle of continuity may provide and medicamentous preparation for the subsequent physio-, balneological, for example, in case of presence in an organism chronic sets of infection.
The specified principle is observed and when after one course of treatment it is necessary to recommend realization of repeated or other rates of physiotherapy
Principle of early assignment of physical medical means (PMM)
PMM may be appointed in the sharp period, right at the beginning of lines of diseases and at traumas: a cold on a head – at concussion or a bruise of a brain; electrostimulation of intestines – at developing it pareses; pulse currents – at sharp painful syndromes; Electric Field of UHF – at sharp inflammatory processes; medical cupping-glass – at a sharp pneumonia; a warm or hot bath – at an attack cholelithiasis. This principle means also duly purpose (assignment) of the physical factor at long processes.
Principle of adequate, individual assignment of physical medical means (principle of an individualization of physiotherapy)
Techniques of realization of one or several various physical procedures should correspond to adaptable opportunities of tissues, body, system or an organism as a whole, feature of development of disease, its phase. The principle also provides methodical features of realization of physiotherapy at children, at persons of elderly and senile age (geriatric physiotherapy) at the weakened patients, at heavy diseases and traumas.
Principle of use of specific properties of physical medical means
Each medical physical factor has any unique, only to it inherent features of the mechanism of action which allow to receive the maximal therapeutic efficiency. The ultrasound, for example, has expressed by resorption action in relation to infiltrates, fresh cicatrices and to solderings. Electric Field of UHF has distinct anti-inflammatory an effect on the fresh purulent centers in depth of tissues. Hydrosulphide baths with increasing concentration of hydrogen sulphide from 100 up to 400 mg/l improve peripheral blood circulation in tissues. Any other means ФТ does not give similar activation of blood circulation. Hypothermal water and air procedures in the greatest measure stimulate systems of immune protection of an organism.
Certainly, in PТ there is a certain interchangeability of physical factors, however, at their choice for the concrete patient it is necessary to prefer those, the mechanism of which medical action in the maximal degree is adequate to features of disease.
Principle of assignment of optimum dosages
In physiotherapy allocate four variants of dosages (on force and durations of influence): very weak, weak, average force and strong.
On adaptable opportunities of an ill organism, from character of disease, a phase of its development, an acuteness of process choose one of variants of construction of a doze. Within the framework of course of treatment batching of procedures may change weak dozes gradually pass in average, strong may weaken and etc.
At strong painful syndromes usually choose weak anesthetizing dosages. At long chronic disease the best results give high or average dozes of physical factors. Sparing influences Physical therapy is expedient at people of elderly and senile age, at children, at the weakened patients, and also in the sharp periods of diseases and traumas.
Between principles of optimum dosages and an individualization of therapy there is a close interrelation as selection of optimum parameters of procedures for the concrete patient always individual.
Principle of integrated approach of physiotherapy
Complex therapy of many chronic polyethyological diseases is always more effective, than monotherapy as it provide polysystem influences on different parts of pathological process. In this plan significant interest represents a combination general (common) and local Physical therapy procedures the general procedures render mainly stimulating or normalizing influence on systems of an organism (nervous, cardiovascular, immune etc.) and through them – on current of local pathological process. Local in the much greater degree influence on очаговые its displays (local blood circulation, permeability of tissues, phagocytosis, producing of biologically active substances, regeneration of tissue etc.)
The complex may be made for treatment of one or several diseases at one person. In the second case danger of failure of adaptation of tissues and an organism grows.
The medical complex may consist only of physical factors that is frequently observed in sanatorium conditions or to include physiotherapy exercises, massage, psychotherapy, medicines etc.
Principle of dynamism of physiotherapy
One of frequently meeting lacks of work of many doctors, it is especial doctors of resort establishments, absence of changes of parameters of a medical complex is during spent therapy.
Patients differently endure same electric-, balneo-,-and fangoprocedures. During treatment average may develop heavy physiobalneoreactions and be observed phase changes of a condition of an organism.
Except for it, according to basic researches of L.Harkavy, E..Kvakinaj and M.A.Ukolovaj, weak dosages of physical influence during a rate of current gradually it is necessary to amplify, and average – wave to change.
Thus, it is necessary to make changes to dosages and structure of a medical complex. Correction of dosages physiotherapeutic procedures provides changes of temperature of water or intensity of ultrasound, the area of influence, duration, alternation of procedures and so forth on the basis of the additional data received during course of treatment.
Principle of the account of biological rhythms
As exist, conditionally named, momentary, daily, monthly, year and other periodic changes of intensity of various functions of an organism, they should be taken into account in assignment of physiotherapy. The physiotherapeutic equipment based on use of the given momentary rhythms of intimate activity (devices “Syncardon, Shpilts” pressures chamber, biostimulator of muscles (devices Myoton, Myocor etc.), rhythms of brain (EEG) – some models of devices of electrodream is known. It is recommended to appoint physiotherapeutic procedures in view of daily rhythms: tonic – it is better in first half of day, sedative – in the second, electrodream – is more expedient in middle of day, electrophoresis on a preparation – in different time of day.
Principle of psychotherapeutic potentiation of physioprocedures
It is known, that at realization of treatment for the patient the considerable role is played with suggestion, autotreining, behaviour of the medical personnel. According to different authors, the psychotherapeutic component in physical therapy has the high importance (30-40 %). The disorder in a study, the negligent attitude, indifference, roughness of the personnel, is doubtless, have negative influence on treatment. And on the contrary, cleanliness, neatness, the order, politeness, the easygoing attitude of physicians to the patient raise efficiency of application PMM. The high estimation the medical personnel appointed physical procedures and concrete acknowledgement of their utility is important. Is expediently duly to tell the patient about an opportunity of occurrence of unpleasant sensations, a time aggravation of disease, mainly in the beginning of course of treatment, occurrence of physiobalneological reactions.
Principle of preventive application PMM
Such physical (physical and chemical) factors as air, Ultra-violet rays, air-and hydroair ions, sauna, fresh and mineral waters, the general massage are the widespread means of initial physioprophylaxis. With their help it is carried out закаливание and improvement of people.
Secondary physioprophylaxis is intended for health improvement of patients with the family, household or professional risk factors promoting development of diseases Besides the specified means, with the preventive purpose electrodream, cerebral (central) electroanesthesia here may be used, communicating franclinization, mechanical prophylaxis, local kinds of massage, inductothermy, electro of medicinal substances etc.
Tertiary physioprophylaxis spent for the prevention of relapses and progress of various diseases, uses all arsenal of physical medical and preventive means.
Rules of arrangement and operation of physiotherapeutic studies (branches). The safety precautions in an operating time in them.
Are necessary for maintenance of safe and optimum operating conditions for the personnel and comfort for patients during realization of physiotherapeutic procedures.
For each treatment from kinds separate premises(rooms) (except for procedures of electrotreatment and a chromophototherapy should be equipped, except for use of stationary high-frequency generators and devices for microwave therapy).
Physiotherapeutic departments (studies) it is forbidden to have in basement, semibasement and socle rooms which level of a sex is below than on
On use of the domestic physiotherapeutic equipment, and also the import, recommended commission oew engineering, the sanction of the Ministry of health protection is necessary.
The rooms of the physiotherapeutic departments (studies) should use only on direct reserving; realization in them of any other kinds of the activity which has beeot connected to use of the physiotherapeutic equipment, – is forbidden.
In the physiotherapeutic departments (studies) the equipment of a room (place) for rest of patients at the rate of
Independent realization of physiotherapeutic procedures is authorized to persons with the special secondary,(supreme) medical education having the certificate of the ending of courses of specialization in a physiotherapy, agrees the program predicated by the Ministry of public health. It is not authorized to carry out physiotherapeutic procedures to the younger medical personnel.
Persons, are more younger than 18 years, are not supposed to work with generators of the high and ultrahigh frequencies, and also, it is forbidden being of them in sphere of influence of the ultra high-frequency and superhigh-frequency radiation.
In the physiotherapeutic departments (studies) should the systemic control will be carried out with the purpose of revealing radioactive radiations, air pollutions by ozone, antibiotics, a hydrogen sulfide, paraffin and by others (proceeding from specificity of procedures) substances.
Galvanic current
It is the current which is not varying the direction in space refers to as as a constant. In system of coordinates, at invariable voltage and resistance of conductors, the direct current is expressed by a direct line.
Periodically closing and breacing the elements of an electric circuit, it is possible to receive an intermitent direct current.
Passage of a constant electric current of small force and pressure (voltage) through tissues of an organism with the medical purpose refers to as galvanizing. At slow and constant increase of force of a current under electrodes the patient in the beginning feels easy pricking, burning and is warm. With increase of force of the current, the above-stated sensations amplify, there is a pain and sensation of squeezing. The described phenomena are caused by irritation of a leather (skin) and irritation of skierves. Alongside with it, quickly accrues redness of the skin, kept on a site of influence, during one hour, and even it is more of the ending of procedure of galvanizing. The temperature of a skin raises a little. Influence of a strong current may cause burns which are painful and badly heal.
During passage of a direct current through a body moving ions to tissues of an organism begins. The ions which have reached (achieved) electrodes, give the charge and chemically active atoms turn in electrical neutral, but. Products of electrolysis (N+, Cl–etc.), reacting with water, may cause burns of a skin (formation Na (K), OH). To avoid burns at realization of galvanizing, between a skin and electrodes lay the west linings moistened with water or solution NaCl due to which between a body and a liquid there is an exchange of ions and products of electrolysis, formed under electrodes, it is direct with a skin do not adjoin.
For realization of procedure of galvanizing it is necessary devices («Stream – 1», «GH – 1 (2)», «RP – 33», «GR – 1 M», etc.) with a source of a direct current, the devices giving an opportunity to measure force of a current and to adjust its size, conductors, clips, electrodes, and also electrode linings and a filtering paper.
Conductors should be well isolated, long 1-
In some cases use various electrodes on the sizes. The greater behind the area refers to as indifferent (or passive), that is less – active that is connected to non-uniform distribution of electric power lines in the field of electrodes: at the same size of a current in a circuit the density of a current (on 1 unit of the area) will be less in the field of an electrode of the small sizes.
Electrode linings make from undial hydrofeel a cotton tissues (a fustian, a flannel etc.). For removal from a new tissues dressing substances, a lining boil within 20-30 minutes in distillated water. To avoid toushing to a body of a metal electrode, linings produce in account on 2-
Depending on, whether influence we on all organism (imposing electrodes on departments of the upper and lower extremities), or on separate sites of a body, distinguish the general (common) and local galvanizing.
For the general galvanizing frequently use a 4-chamber bath. It consists of four small, as a rule ceramic trays for the upper and lower extremities.
A 4-chamber bath
Each of trays is equipped with 1 or 2 coal electrodes. Trays fill water (36-370 C). The special switchboard built – in an electric circuit enables to connect any of trays to the necessary pole.
Proceeding from an arrangement of electrodes in relation to subjected электризации to a site of a body distinguish longitudinal and cross galvanizing.
So, for example, for galvanizing a spinal cord one electrode is imposed on area cervical vertebras, another – on cross-section – lumbar area (longitudinal galvanizing). If the narrow and long electrode is imposed on all backbone, and another, same – on a forward surface of a trunk is a galvanizing cross.
At diseases of a brain galvanizing on Burgynjon is applied: one electrode is imposed on area of an eyeball, another – on a back surface of a neck.
With the purpose to cause a reflex from skin zones (at level of C2-D3) use a galvanic collar on Scherbak: one electrode (as a collaret) place on a humeral zone, another – on sacrum area.
At defeats of obverse and trigeminal nerves the electrode as halp-mask of Bergonjy which is imposed on the appropriate half of person is applied; other electrode have on an external surface of a shoulder of the opposite side.
In case of defeat of a sciatic nerve one electrode lay in buttock (lumbar-sacrum) areas, another – on a back surface of lower half of calf muscle.
Cross galvanizing is applied at diseases of joints, internal organs (electrodes, thus, are established so at proper place of the body was in a zone of the maximal concentration of electric power lines.
With the medical purpose it is used as a continuous direct current – stable galvanizing, and intermitent – faltering galvanizing.
Technique of stable galvanizing.
Before the beginning of procedure it is necessary to be convinced, whether there is a handle of a potentiometer in zero position and to be convinced of reliability of all contacts. On a site of a leather where galvanizing will be carried out, the electrode linings moistened with warm water or heating up by solution NaCl are imposed. Atop of linings metal electrodes are established; all this is fixed by bandage (sacs with sand or weight of a body of the patient).
It is necessary to achieve uniform, without folds, close-fitting an electrode and linings to a body, differently the density of a current not everywhere will be identical, that may result in burns. An electrode before the use it is necessary carefully to make iqual. Under a clip, in a place of its contact with a lining lay a piece of an oilcloth.
Linings, before the use, are boiled in water water, than their sterility is reached. Except for it, in time boiling from them harmful substances leave fat, exfoliating epithelium and some, formed in result of electrolysis. Often washing of linings – the necessary condition of removal harmful ions working on an organism. The lining densely should adjoin the same surface to an electrode. With this purpose to its appropriate surface sew pocket in which place an electrode.
Force of a current during realization of stable galvanizing should be increased slowly and gradually. The patient should feel under a lining easy pricking and burning (similar to action of a mustard plaster). Occurrence of morbidity on limited zones testifies or to non-uniform contact of a surface of a body to an electrode and a lining, or about damage of skin that may cause a burn. Therefore before procedure carefully it is necessary to examine the site of skin subject of galvanizing, and all available damages to isolate, having covered with their cotton wool greased with vaseline or a slice of oilcloth.
Sometimes, at a constant voltage, force of a current, owing to reduction of a voltage may reach significant size, that too may threaten the patient with a burn. In this connection, at galvanizing all time is necessary to watch sensations of the patient, simultaneously, behind indications of a galvanometer, changing, as required force of a current in this or that side.
To switch off a current it is necessary as slowly and gradually as well as to include. Duration of stable galvanizing – 20-30 minutes. Course of treatment makes 10-20 procedures, if necessary to continue treatment, it is necessary to make a break for 20-30 days then it is possible to carry out galvanizing again.
Physiological action of galvanizing.
In an organism arise physic and chemical changes, caused to processes of carry of ions, particles of water and colloids.
Under influence of an electric field positively charged ions move to the cathode, negative – to the anode. Under the cathode ions of hydrogen, under the anode – OH- ions collect. Changes РН arising at it essentially influence on colloids condition and functions of cells.
Alongside with Н– ions to the cathode others direct also other cations (K+ and Ná +), near the anode the opposite phenomenon is observed: as a result of outflow univalent cations, a parity one – and bivalent ions (Ca2+, Mg2+) is displaced aside overweight of the last that has the big value whereas of colloids dispersiveness depends not only on a mark of a charge, but also from valency of ions. The heap in the field of the cathode on a surface of cellular membranes of metal univalent ions causes them to loosening, increasing permeability of membranes of cells (cages) for many reagents (substances). So penetration into cell H- ions changes a condition of fibers, that physiologically is shown by increase of excitability. Under the anode where there is an accumulation of ions Ca2+ and Mg2+, on the contrary, cellular membranes are condensed, their permeability decreases, excitability falls.
Similar sort functional changes in the field of electrodes refer to as cathelectrone and anelectron.
Functional changing in tissues depend not only on character of irritant, but also from a functional condition of organism on which it operates. So cathodic influence raises nervous elements in their normal physiological condition, or, on the contrary, oppresses excitability of a nerve, before it undergone influence of parabiotic factors. Changes are observed not only in peripheral nerves, but also in central nervous system (CNS).
Therapeutic application of a direct current is based on features of its physiological action. At decrease of functional activity of tissues, influence on them a direct current of small intensity increases their excitability under the cathode, and, on the contrary, under the anode excitability of tissues decreases, that not may be use with the medical purpose when the phenomena of irritation and a painful syndrome are observed.
Under influence of a direct current there is an amplification of metabolic processes (a nitrogenous metabolism in the field of the cathode and carbohydrate in the field of the anode), changes РН.
It, appreciably, determines therapeutic influence of galvanizing: the positive influence on the inflammatory processes; stimulation of regeneration; resorption of scars.
The galvanic current is widely applied in cases when it is necessary to cause irritation (stimulation) of nerves and muscles. In these cases use short-term disconnection of a current.
With the help of a constant electric current it is possible to influence tissues and organs of an organism directly and reflexly.
Indications for galvanizing:
– diseases of peripheral nervous system (a neuralgia, radiculitises);
– functional disorderes and mechanical damages of central nervous system (CNS), including, a migraine;
– gastritises, colitis, a stomach ulcer;
– a dyskinesia of a biliary ducts;
– a bronchial asthma, vasomotor a rhinitis;
– hypertonic illness of І–ІІ stages;
Contra-indications:
– tumours;
– system diseases of blood;
– diseases of blood circulations system: hypertonic illness of ІІ–ІІІ stages; an astable stenocardia; the diseases accompanying of cardiac insufficiency of stages;
– an active tuberculosis;
– propensity to bleedings;
– emaciation;
IONOPHORESIS
Ionophoresis has been described as a method of facilitating the transfer of ions by means of an electrical potential into soft or hard tissues of the body for therapeutic purposes. It is a noninvasive procedure whereby free ions are applied topically into the skin using direct current. Ionophoresis is based on Faraday’s law of electrolysis: M = nIT/ZF, where M is the number of moles of a given ion that will be released by the passage of I amperes of charge of the same polarity as the drug molecule during each second of the ejection time (T). The number of ions delivered depends on the valence of the charged ion (Z) and the Faraday constant (F). The relationship between the passage of charge and the passage of charged ions depends on the complex factor n, known as the transport number, which varies for individual compounds as an expression of their solubility, polarity, and type of media into which the molecules are ejected. Simply put, the basis of ionophoresis is that an electrically charged electrode will repel a similarly charged ion.
Historical Background
The uses of ionophoresis have been studied by professionals from different backgrounds—physicians, dentists, pharmaceutical scientists, chemical engineers, biologists, and physical dierapists. It was found to be useful not only for local conditions but also for systemic delivery of drugs, in particular proteins and peptide drugs.
In 1747, Veratti described the application of electric current to increase penetration of drugs into surface tissues. The first controlled study was done in 1900 by LeDuc using strychnine and cyanide ions in rabbits. One of the well-known applications of ionophoresis is for treatment of hyperhidrosis based on studies done by Ichihashi in 1936. The sweat test used to diagnose cystic fibrosis, first used by Gibson and Cooke, is performed using ionophoresis with topically applied pilo-carpine to induce sweating.
Mechanism of Action
Acids, bases, salts, and alkaloids are ionizable substances that dissociate into their component charged ions when dissolved in water. The resulting solution with electrolytes is capable of conducting electric current by virtue of migration of the dissociated ions. When a continuous direct galvanic current (DC) is passed between two electrodes in an electrolyte solution, the cathode (negative pole) will attract positive ions, and the anode (positive pole) will attract negative ions. Ionophoresis is the transfer of ions into the body by this method for therapeutic purposes. Membrane barriers made up of lipids and proteins are present in the skin and other surface tissues; thus, ionized compounds are less easily absorbed than nonionized compounds. The rate of membrane penetration of ionized drugs may be increased by means of an electrical source. The process of ionophoresis provides this electrical energy source for passage across the membrane. The skin has an isoelectric point of around 3-4. When in contact with solutions with a pH of less than 3, it carries a net positive charge. When in contact with solutions with a pH of greater than 4, it carries a net negative charge. A negative charge on the skin during ionophoresis causes electro-osmotic movement of water from within the body toward the outer surface of the skin, anode to cathode. This water movement may result in pore shrinkage at the anode and pore swelling at the cathode. Thus cation transfer may occur during anodal ionophoresis in the same direction as the water flow.
Factors Affecting lonophoretic Transport
Ionic Strength
The ionic strength of a solution is related to the concentration of the various ions in the solution. Migration of a particular ion requires that an ion of the opposite charge should also be present in close proximity. The pH of the delivery medication is often controlled by the addition of buffering agents, in which the ions are usually more mobile than the ions meant for ionophoretic delivery. This has a retarding effect on the protein of the ion, which should be delivered ionophoretically into a tissue. Ideally, the use of a buffer system should be avoided in ionophoresis, but if that is not possible, buffers containing ions with low mobility or conductivity are preferred. The drug transport in skin always is less than unity owing to the pressure of endogenous ions, such as bicarbonate, potassium, chloride, which carry a sizable fraction of ionic current.
Vehicle pH
Vehicle pH is important for drugs whose degree of ionization is pH dependent. The optimum pH for ionophoretic delivery is where the compound exists in an ionized form. Siddiqui and colleagues studied the effect of pH on the rate and extent of lidocaine ionophoresis through the skin. The rate of penetration was highest at the pH where lidocaine existed in the ionized form. The pH changes become significant for protein and other drugs because the pH of the solution changes the charge on these molecules. For example, greater skin permeability has been shown at a pH below its iso-electric pH for drugs such as insulin.
Current Strength
A linear relationship between the applied current and the movement of the compound has been observed. However, the maximum strength that can be used is limited by consideration for patient safety. The maximum tolerable current increases with the electrode area. The upper limit of current strength for clinical use has been suggested to be 0.5 mA/cm2
Concentration
The effect of the solute concentration may be determined by the Nerst-Planck equation. However, it is possible that at higher concentrations, the transport may become independent of concentrate owing to the saturation of the boundary layer relative to the saturation of the donor solution.
Electro-osmotic Transport
An electrically driven flow of ions across a membrane with a net charge can produce a flow of solvent called electro-osmosis. Delivery of compounds through the anode has been observed to be higher than those delivered through the cathode.
Continuous versus Pulsed Current
Use of continuous direct current may result in skin polarization, which can reduce the efficiency of the ionophoretic delivery system. A pulsed direct current delivered periodically can overcome this problem.
Physiologic Factors
Limited studies have suggested that ionophoretic delivery may be independent of the type of skin studied. Ionophoresis using lithium and pyridostigmine through human, pig, and rabbit skin have been found to be comparable. Insulin delivery through hairless rat skin was comparable to fuzzy rat skin. Factors such as age, race, skin thickness, degree of hydration, and normal versus diseased skin have yet to be studied. The effect of dermal blood flow on ionophoresis has been shown in pigs using lidocaine delivery in the presence of vaso-active chemicals (epinephrine). There was a decrease in lidocaine flux because of lidocaine’s vaso-constrictor effect compared with use of tolazoline, which increased the ionophoretic lidocaine flux caused by its vasodilator effect.
Therapeutic Applications of Ionophoresis
Ionophoresis has many advantages that render it a desirable modality for drug delivery. Some of the advantages are similar to those of phonophoresis, including the noninvasive nature of the procedure, low risk of infection, systemic absorption, and enhanced drug penetration. Additionally, the ionophoresis unit is available for home use and provides a simplified therapeutic regimen, which helps with compliance. Disadvantages of the procedure are that it can be time consuming, and minor skin irritation and burning can occur with treatment.
Inflammatory conditions such as bursitis, tendinitis, strains, and sprains have been successfully treated using dexamethasone sodium phosphate combined with lidocaine (Xylocaine) iontophoresis. Glass and associates demonstrated effectiveness of ionophoresis in a series of animal studies with rhesus monkeys by introducing radiolabeled dexamethasone sodium phosphate into tissues surrounding major joints including tendons and cartilage. Ionophoresis using acetic acid has been reported to treat successfully calcifying tendinitis of the shoulder in humans and traumatic myositis ossificans in the quadriceps femoris muscle. Banta found outstanding results with his patients with carpal tunnel syndrome using dexamethasone. In this study, more than 58% of the subjects had a positive response to ionophoresis, and he suggested that this is an excellent alternative to steroid injections.Other conditions found useful for treatment are skin conditions such as hyperhidrosis, small open ulcers, and fungal infections. Ionophoresis has also been used to administer local anaesthetics for dental, ear, nose, throat, and eye procedures. Edema reduction using hyaluronidase, which appears to increase absorption of fluid from skin and subcutaneous tissue, has been attempted, but as with other edema-reduction techniques, the effect is short-lived. Table 1 contains a list of the most commonly used ions and their respective polarity.
Table 1. Commonly Used Ions with Ionophoresis
Ion Polarity Indication
Dexamthasone – Musculoskeletal inflammatory conditions
Acetate – Calcium deposits
Lidocaine + Analgesic agent
Hyaluronidase + Edema reduction
Zinc + Ischemic ulcers
Copper + Fungal infections of feet
General Principles of Application
Identification of the appropriate ion and its polarity for treating the presenting pathology is paramount for successful treatment. Some ions, such as those in iron, silver, copper, and zinc, form insoluble precipitates as they pass into the tissues and should be avoided. Other important factors that influence outcome are the depth of penetration, number of ions transferred, and whether vascular transportation of the ions carry away from the application site. The number of ions transferred into the body is dependent on three factors: the current density, duration of the current flow, and the concentration of ions in the solution. The current density is determined by the size of the electrode used the smaller the electrodes, the higher the density. To decrease the caustic alkaline reaction in the body tissue that occurs under the cathode, the surface area of the cathode is always at least twice that of the anode. Normal intact skin is intolerant of current densities greater that 1 mA/cm2. This impedance is further lowered in abraded or lacerated skin, fair skin, and scarred skin. The anesthetic effect produced under the electrodes poses a high risk for electrical burns. Therefore, close monitoring and caution is advised during treatment. Research on the penetration and distribution of ions with ionophoresis has demonstrated effectiveness. Several studies have indicated that ions penetrate and have therapeutic effects on deep structures. More recently, Costello found penetration of at least 1 cm into the gluteal muscles of rabbits when using lidocaine with ionophoresis. His ideal parameters for ion penetration were current of 4 mA for 10 minutes, with a 4% lidocaine solution.
Equipment
Three types of equipment are available for ionophoresis: line-operated units, simple battery-operated units, and rechargeable power units. Line-operated units are used mostly for the pilocarpine ionophoresis sweat test in cystic fibrosis. Because of the potential for electric shock from the wall outlets, battery-operated units were developed.
Battery-operated units are available for commercial and home use. A more sophisticated multipurpose unit, called the Phoresor, is popular in dentistry and physical therapy. The Phoresor runs on a 9-volt battery with a 45-volt DC transformer. It delivers a constant current and adjusts to change in resistance in the external circuit during the procedure. It is equipped with safety features including a limited maximal rate of current of 2 mA/sec to prevent shock. The actual procedure entails massaging the chosen drug solution or cream into the bare skin over the area to be treated or placing a towel soaked with the drug solution on the skin to be treated. The active pad electrode made of tin, aluminum foil, or commercial metal electrode that has the same polarity as the ions is placed over the towel. Avoiding direct contact between the pad and skin is essential to prevent chemical burns. On the other hand, good contact between the electrode and towel and between the towel and skin is needed to avoid “hot spots” from increased current density. A second electrode pad, moistened with tap water or saline solution, is placed at a distance on the same side as the active electrode. The lead wires from the pads are connected to the appropriate generator terminals. The amplitude of the current is set to achieve current density between 0.1 and 0.5 mA/cm2. The duration of treatment can be up to 15 minutes, depending on die patient’s comfort.
Today, several brands of electrodes are available that allow for simple drug delivery. With these modern electrode systems, the ion solution is simply injected onto the drug delivery electrode, saturating it. The pads come in various sizes, each with their respective drug fill volume. This pad is placed over the treatment area, and a separate dispersive pad is placed over a muscle group at least 6 inches away. The lead clips are attached to the appropriate electrodes, and the unit is turned on. For inflammatory musculo-skeletal conditions, these authors typically use of dexamethasone with the following settings:
Dose: 40 mA.-min
Current: 2 mA.
Treatment time: 20 minutes
The newer Phoresor units automatically calculate the treatment time once the dose and current variables have been selected. These units sound an audible alarm and shut down once the treatment time is complete. Figure 1 shows a Phoresor in use with electrode placement for treatment of lateral epicondylitis.
Summary
Ionophoresis has enjoyed considerable success in the treatment of musculoskeletal and dermatologic conditions. With use of appropriate parameters, it has proven to be a safe and effective modality. As knowledge of the mechanism and physiology of the ionophoretic process increases, the potential for its use for drug delivery in the treatment of musculo-skeletal conditions expands.
Electrodream therapy(EDT)
EDT – a method of electrotherapy which is based on action by a pulse current of low frequency (1-150 Hz ) and small force (2-8 mA ) it is direct on structures of a brain.
Devices: ” ELECTRODREAM –3,4,4-T,5 “, “LENAR”.
For conducting procedure it is necessary a comfortable couch and quiet black-out room. An electric current is tricked to the patient by the special electrodes. A cathode is imposed on eyelids, and in the case of the unpleasant feelings of patient – on a frontal area, and anode – on the area of processus mastoideus. At such placing of electrodes anode which make a brake action is in 3 times nearer to the reticular structure, than cathode which has activating action.
A reticular structure occupies an area from hypothalamus to the medulla oblongata and has an activating influence on a cortex. At action of impulsive electric current, under an anode a reticular structure is braked that causes deppression of cortex.
Depression of activity of reticular structure blockade the transmissions of impulses to thalamus, hypothalamus and lymbyc system, where feeling of pain, vegetative, endocrine and emotional reactions on pain is formed. Consequently, electro-sleep has the anaestetic action.
Electro-sleep can be applied at the degenerative and functional changes of cerebrum. At the degenerative changes apply frequency 5-20 Hertzs, and at functional – 60-120 Hertzs. It is explained that at frequency to 20 Hertzs the sympatic part of the vegetative nervous system is activated. Frequency 60-120 Hertzs activate the sympatic part of the vegetative nervous system.
Apparatus: “ Electrodream -2“, “ Electrodream -3“(for 4th patients), “ Electrodream -4“, “ Electrodream -4Т“(small transistor), “ Electrodream -5“, “Lenar“.
The impulses of small frequency (100-200 Hertzs) are used in the apparatus “electro-sleep”, and in a place, where the electrodes located (eyeballs, processus mastoideus ) take place the phenomena of electrolysis, which cause the unpleasant feelings under electrodes. In the apparat “Ленар” impulses are used by frequency to 2000 Hertzs and the phenomena of electrolysis are insignificant, and is therefore removed the unpleasant subjective feelings on a skin.
Duration of procedure – from 15-30 min to 1 hour, 10-20 procedures on the course of treatment daily or in a day. During conducting of procedure of electrosleep a patient feels easy occasionally, “ant crawl”, “breeze” in the area of eyelids. If these feelings are unpleasant, it is necessary to change eyeing-papillary on a frontal-papillary method.
The mechanism of action:
( initial physical and chemical and physiological influences)
· normalization of a parity of the basic nervous (cortex-subcortex) processes;
· improvement of a functional condition of a vegetative department of the central nervous system and endocrine regulation;
· increasing of the general reactance of an organism;
· central analgetic action;
· inductive influence on the vasomotor and respiratory centres.
Therapeutic effects:
· sedative;
· trophic;
· spasmolytic;
· hypotensive;
· secretory (incretory).
The indications: neurosises, neuralgias, encephalitises, consequences of the craniocereberal traumas, disordes of dream; hypertonic disease of I-II stages; ischemic disease of heart; peptic stomach and duodenum ulcers; bronchial asthma; hypofunction of thyroid; diabetes; neurodermitises, eczema, enuresis, phantom pains; conditions after radical operations in oncological patients.
Contra-indications: general to physiotherapeutic procedures; epilepsy; inflammation or defects of the skin in a place of imposing of electrodes; presence of metal splinters in a brain; intolerance of a current; retinal detachment; traumatic arachnoiditis; some disease of eyes.
Diadynamic Therapy (DDT)
DDT– a method of electrotherapy which uses action of two constant pulse currents by frequency 50 Hz and 100 Hz of small force (up to 50 mA ) it is independent or in a combination.
Onetact continuous (OC), monophase fixed current of 50 Hertzs frequency. Under act of onetact current take place the intensive contractive of muscles. A current has the excites action. This current uses for patient with paresises, paralyses for stimulation the contractility of muscles.
Twotact continuous (TC), diphasic fixed current with frequency 100 Hertzs. Conductivity of skin grows, the threshold of sensitiveness rises, a brake, anaesthetic effect activates under the action of twotact current. This type of current is applied in medical practice for liquidation of pain, spasms and to increase the conductivity of tissues.
Irregular onetact rhythmic (OR) current is “rhythm syncope” with frequency 50 Hertzs. The action lasts 1,5 с whereupon comes pause of the same duration. During action of current “rhythm syncope” during 1,5 с a patient feels reduction of muscles. This type of current is used for electro-stimulation of muscles.
Current modulated by short periods (SP) – it is combination of onetact and twotact currents, that is alternated through 1 s. As a result circulation of blood increases, vessels widen, motion of blood accelerates, the temperature of body in the area of action rises.
Current modulated by long periods (LP). A long period is the combination of onetact current, duration of which 4 s and twotact current, duration of which 8 s. During 4 s actions of twotact current patient feel intensive reduction of muscles, which changes by tender vibration during 8 s action of twotact current. That LP operates like SP, but slower and more soft.
Onetact waving (OW) is an impulsive current with frequency 50 Hertzs, force of which grows and falls in every impulse. That provides mildle action, comparative with action OC.
Twotact waving (TW) current is an impulsive current with frequency 100 Hertzs, force of which grows and falls in every impulse. That provides mildle action, comparative with action TC.
The most expressive anaesthetic effect have SP and LP.
Waving currents cases the influence on the circulation of blood.
Electrodes for diadynamotherapy have such self structure, as well as electrodes for galvanization. Into sickly place a cathode is imposed. If on a sickly place located two electrodes (cathode and anode) in the meadle of procedure it follows to change their polarity on opposite by a switch on a apparate.
Procedure is begun with the TC or TW application.
As a rule is often used such combination of diadynamic current:
At first LP or TW – 0,5-1 min;
Then SP – 2-3 min;
After this LP – 1-3 min.
Devices:”SNIM-
DT 50-3
The mechanism of action:
( Initial physical , chemical and physiological influences)
Single-cycle currents:
· dynamic effect;
· the expressed irritating and exciting action.
Duple currents:
· increase of a threshold of sensitivity of peripheral receptors;
· decrease of the peripheral nervous receptors exciting ;
· expansion arteriols and capillaries;
· increase of the tissues” electric conductivity ;
· activation of microcirculation and lymph flow ;
Therapeutic effects:
· dynamic;
· vasomotor;
· trophic;
· anesthetizing;
· anti-inflammatory.
The indications: radiculitises; myositises; bruises, stretching of ligaments; periarthritises; arthritises; atonic and spastic colitises; dyskinesia of biliary ducts; gastritises; migraine; obliterating endarteritis, Reynaud” syndrome; hypertonic diseases of II-III stages and etc.
Contra-indications:
general to physiotherapeutic procedures; acute inflammatory processes; pregnancy; acute myocardial infarction (and a condition about 6 months after it ); fresh crises, dislocations and hematomas; thrombophlebitis; urolithiasis and cholelithiasis .
Amplipulse Therapy
It is a method of treatment at which on the patient influence variable sine wave modulated currents (SMC) of small force.
The main medical factor is the variable sine wave current with frequency 5000 Hz, modulated by low frequencies about 10 up to 150 Hz. As a result of modulation packs or series of pulses of the current separated from each other by intervals with zero amplitude are formed. altering influence of such series of fluctuations on a tissue considerably raises their stimulating action and reduces accustoming to them of an organism.
“АPT” causes to activation of blood circulation, functions of external breath. The sine wave modulated currents increase arterial inflow and venous outflow that causes increase of temperature of tissues on 0,8-
SMC on a way and parameters of used influences are capable to render many-sided influence on a tone and contractive ability of muscles. It is applied at a pathology of nervous – muscular system when electrostimulation of nerves of muscles is made, and to restoration of functions of various bodies and systems. Such influences I am applied for increase of a tone of atonic bilious bubble, stomach and an intestines, for exile of stones from ureters, for restoration of the motor activity of uterus pipes at tube barreness.
SMC in the straightened mode have electrophoresis ability. For “APT” use a kind of work, frequency of modulation 150 Hz, depth of modulation of 75-100 %. Procedures will carry out(spend) within 10-15 minutes. Alongside with medicinal electrophoresis “APT” combine with mud cure (APPT), criotherapy (crioamplipulsphoresis-CAP), ultrasonic therapy (amplipulsphonophoresis-APP).
Parameters. In modern devices of type “Amplipuls” carrying frequency of 5000 Hz, modulated by low frequency, is exposed, besides to three more kinds of modulation that provides a set of currents for five kinds of work (KW).
Unstraightened current Straightened current
modes modes
At1-st KW carrying frequency of a variable sine wave current 5000 Hz is modulated by one of the frequencies chosen from a range 10-150 Hz. Force of stimulating effect accrues with reduction of frequency of modulation and increase of its depth.
At 2-nd KW sendings of the sine wave current modulated by certain frequency within the limits of 10-150 Hz, and pauses alternate. Thus duration of parcels(sendings) of a current and pauses may be adjusted separately in limits from 1 up to 6 with. Such mode has the most expressed neurostimus effect.
At 3-d KW sendings of the modulated current with any way chosen frequency with parcels (sendings) of the not modulated current frequency 5000 Hz alternate. Duration of sendings also may be adjusted discretely in limits from 1 up to 6 with. In such mode it begins to be shown analgetic effect.
At 4-th KW alternation of sendings of a current with different frequencies of modulation is carried out. In one of sendings frequency of modulation gets out of a range 10-150 Hz, in the second frequency of modulation is a constant – 150 Hz. The sine wave modulated currents render the greatest analgetic effect which grows at reduction of a difference between frequency 150 Hz and the elected frequency of modulation.
5-th KW differs from 4-th kind that any way modulated current alternates with a current modulated by frequency 150 Hz , and the subsequent pause.
In all specified sorts of work probably change of depth of modulation from 0 up to 100 % and more. Irritating effect of a current grows at reduction of frequency and increase of depth of modulation, and also at switching by the straightened mode. Stimulating action may change on duration of sendings and pauses.
Action of “APT” causes the expressed anesthetizing effect. For this purpose usually I use a variable mode of operation, 3-d and 4-th a kind of work, frequency of modulations of 75 %, duration of sendings of a series of the modulated fluctuations and pauses – 2-3 with, force of a current – up to sensation of the expressed vibration, duration of influence of 3-5 min. for each sort of work. Procedures appoint daily. Course of treatment – 8-10 procedures. At strong pains of procedure it is possible to carry out 2 times per day with an interval 5-6 hours.
Medical effects: stimulating the nervous and muscular tone, anesthelizing, trophic.
Indications: diseases of peripheral nervous system with a painful syndrome (neuralgia, neuritises, radiculitises and plexitises), diseases of a vegetative department of nervous system Reynoud”s disease, hypertonic disease of І–ІІ stages, diseases of Respiratory System (chronic bronchitises, a chronic pneumonia, a bronchial asthma), gastroenterological diseases (functional gastric disturbance, ulcer of the stomach and duodenum, refleux esophagitis, dyskinesia of biliary ducts,diseases of joints (arthritises, deforming arthrosises),nocturia, chronic inflammatory diseases of female sexual sphere, an impotence of functional character.
Taking into account ability SMC is deep to penetrate into tissues, not causing thus of unpleasant sensations and burns, “APT” gives preference (before Diadinamic therapy) in pediatric practice, at influences on mucous membranes.
Contra-indications: fractures (open, comminuted) of extremities, the cholelithiasis and urolithiasis , the increased sensitivity to an electric current, veines” variccose .
The equipment. Procedures carry out with the help of devices “Amplipuls-
Amplipuls therapy use the electrotherapeutic apparatuss also, such as two chanel “BTL-
BTL-05
Electrodes are made from staniole.
Electrodes for amplipulstherapy
In a list of assignments the area of influence, a mode of operation, a sequence of application of currents (kind of work), their duration, frequency and depth of modulation, duration of parcels and pauses, total of procedures is underlined.
The noted apparatus allows to apply 4 types of work.
I – permanent modulation (PM), modulation of fundamental frequency is carried out 5000 Hertzs some one of frequencies of range 10-150 Hertzs. Carries out irritating action on muscular tissues. Apply for electro-stimulation.
ІІ – reference of pauses (RP), references of the sinusoidal current modulated by frequency within the limits of 10-150 Hertzs and pauses by duration 1-6 s. Carries out expressive irritating action on muscular tissues. Apply for electro-stimulation.
ІІІ – reference of the modulated and unmodulated current (RU), the SMC references with frequency 10-150 Hertzs and the unmodulated current by frequency 5000 Hertzs. The change of references takes place through 1-6 с. Apply for the removal of pain.
ІV – reference the modulated currents of two different frequencies (RF), with frequency 10-150 Hertzs and only 150 Hertzs. The change of references takes place through 1-6 с. Apply for the removal of pain.
On the whole, if it is needed to activate activity apply I and the ІІ types of work, if to decrease the activity – ІІІ and ІV types of work.
Technique. Procedures of “APT” will carry out at the maximal relaxation of muscles. Use lamellar electrodes which must influence on a body through linings thickness of
Before the beginning of procedure check the apparatus serviceability. After inclusion of the device in a network one of display green bulbs of ranges “
Upon termination of procedure the sound signal and a current going to the patient is distributed, automatically switched off. The handle of a regulator of a current needs to be removed in extreme left position to disconnect the device from a network and to take off electrodes from a body of the patient. Hydroabsorbing linings after procedure wash out, boil and dry up.
Duration spent daily or in day of procedures does not exceed 20-30 minutes. Course of treatment makes 6-10 procedures. At a strong painful syndrome of procedure it is possible to carry out 2 times per day.
Fluctuorization
It is the method of electrotherapy with using of sinusoid alternating current of small force and small tension, which is helter-skelter changing after amplitude and frequency within the limits of 100-2000 Hz
Due to the disorderly change of parameters of fluctuorization currents at all time actions, the phenomena of adaptation do not develop in tissues.
The current of the noted frequency easily overcome the resistance of skin and less branchs out.
For fluctuorization 3 forms of current are applied:
1. Twopolar symmetric fluctuorization current, when chaotically impulses changeable after amplitude and frequency are thrown out as in positive and iegative polarity.
2. Twopolar asymmetrical fluctuorization current, when chaotically impulses changeable after amplitude and frequency are thrown out mainly iegative polarity. 2-3 impulses landings iegative answer every impulses landing in positive polarity.
3. Onepolar straightened fluctuorization current, when chaotically impulses changeable after amplitude and frequency are thrown out only in one polarity (negative), and impulses in other polarity are absent. As a rule is used for introduction of medicine (fluctuorophores).
Fluctuorization currents, as well as all impulsive currents, have the painless and antiinflamable action.
Activity of fybroblasts rises at action of fluctuorization currents, that promotes the enclosing of inflammatory process.
Especially widely fluctuorization currents apply in stomatology.
Indication:
– parodonthosis, alveolitis
– inflammatory diseases of cranial nerves
– diseases of muscle-bone apparatus
Contra- indication:
the same as for diadynamotherapy
Apparatus: “АСB-2-1 “
3 doses of fluctuorization are applied depending on the closeness of current:
· small – to 1 мА/см2 (a patient feels a lightly occasional stitch);
· middle – 1-2 мА/см2 (a patient feels weak unsickly vibration in the area of influencing);
· large – more than 2 мА/см2 (a patient feels vibration which is accompanied by reduction of muscles).
Duration of procedure 5-20 min, conduct every day or in a day. On a course treatments appoint 5-15 procedures.
Interferenstherapy
Using with the medical purpose of interference currents, forming appear in tissues after imposition of two alternating currents with the same amplitude, but with different frequencies.
During procedure on the body of patient 2 independent pair of electrodes are imposed, the force lines of which are cross into tissue in the area of pathological process. In a method apply alternating sinusoid currents with frequencies in an interval from 3000 to 5000 Hz. Thus current, that is given from one pair of electrodes has unchanging frequency, for example 4000 Hz, and from the second pair – frequency which differs from frequency of first pair on 1-100 Hz, for example 3900 Hz, the difference of frequencies can be regulated. Into tissues these 2 independent currents are imposed on each other and as a result of interference there is an actively operating current. Thus high-frequency is used only for facilitation of passing of current in tissues, and the difference of frequencies of currents which are crossed in tissues is an operating factor. Consequently, the noted higher impulsive currents appear into tissues and by these interferenstherapy differs from amplypulstherapy.
2 forms of vibrations are selected:
· “beating” (the changes of amplitude take place with identical frequency and in an identical measure);
· “spectrum” (the changes of amplitude take place not with identical frequency).
Alternating currents freely pass deep into tissues, not causing the unpleasant feelings. It provides soft action and good bearable of procedure.
On the whole, medical action of interference currents yields. Therefore, interferenstherapy apply mainly in the acute period of illness, at times in subacute. At chronic process this current are ineffective. Therefore, these currents combine with electrotherapy (diadynamotherapy, medical electrophoresis and other) and other physiotherapy methods (massage, peloidotherapy, ultrasonic therapy, microwave therapy).
Apparatus: “Interferema“, “Nemektrodin“, “Interdin“, “Stereoordinator-728″.
Electrodes are placed on the soft areas of body. During procedure a patient must feel clear pleasant vibration. Duration of procedure from 10 min. to 30 min. Procedures are conducted every day or in a day. On a course treatments appoint 10-20 procedures. The repeated course of treatment is conducted in 12-15 days
Electrical Modalities in Musculoskeletal and Pain Medicine
The torpedo fish with electricity generating organs was used by Roman physicians to treat gout and headaches in A.D. 46. In Western medicine, the first therapeutic electrical device was reported in 1744 for the treatment of finger paralysis. It was later used as a treatment of arthritis in 1747. Electrotherapy was viewed with varying degrees of acceptance by the medical establishment and was often considered a form of quackery. In the late 19th century, gynecologists used electricity through needles to treat uterine fibroids. Unfortunately, deaths were reported from peritonitis. Static electricity was used to treat a myriad of conditions through the early 20th century. Short-wave diathermy replaced most static electricity units in the 20th century. Since then, a variety of electrical applications have been developed with varying degrees of scientific confirmation. Despite of electrotherapy’s illustrious past, many physicians today are skeptical of claims of its clinical improvements for a variety of ailments. The best proved and most accepted use of therapeutic electricity is defibrillation in cardiac arrest. New theories on pain in the 1960s led to the development of electrical modalities to treat pain. The dorsal column spinal cord stimulator and the transcutaneous electrical nerve stimulation (TENS) unit were practical applications of the theory. Electrical muscle stimulation has been used to treat musculoskeletal and neuromuscular injuries and illnesses. This modality is used by physical therapists and by athletic trainers.
At one time, electrical modalities were within the domain of physical therapists. Practice patterns in the use of electrical modalities have changed largely due to managed-care medicine. Physical therapists are no longer given the time or the authorization to see a patient for more than a few visits, making the instruction of a home exercise program the top priority. Many of the passive modalities are no longer used. However, athletic trainers commonly use muscle electrical stimulation. Electrotherapy continues to be used, particularly by pain medicine practitioners. Electrotherapy units have been designed for home use. The positive influence of managed care has been the challenge to the medical establishment to provide evidence that particular treatments are efficacious. Research with electrical modalities has been methodologically challenging, given the difficulty in designing a truly masked placebo. Many stimulation protocols call for the user to perceive a sensation or experience muscle contractions. Analysis of outcomes often involves subjective measures of pain such as the visual analog scale (VAS). The results of the VAS reported as a mean is considered an unreliable statistic, and the median is the more favored statistic. Unfortunately, the mean of the VAS is a common result in much of the pain literature. A backlash of the evidence based review of the literature is little scientific support for the modalities, lessening the potential for third-party reimbursement. However, the outcome measured in a study can be particularly important. The emphasis on reduction in opioid use is important, although likely multifactorial. The duration of the reduction of opioid use also remains an important outcome to measure, particularly in chronic pain populations. Regardless, the potential to provide patients with a non-pharmacologic alternative, particularly during work hours, is important. In employed chronic pain sufferers, opioid analgesics are not well tolerated owing to the side effect of drowsiness. If 40% of patients experience reduction in pain and medication intake from the placebo effect with electrical modalities, then there is a clinical benefit. However, cost remains a factor. An analysis would need to compare the cost savings in medication reduction and increased work productivity with the cost of the electricunit and its maintenance. This chapter reviews the research regarding the physiologic responses to electrical modalities, the medical evidence to support its use clinically, indications and contraindications, and the cost of home units.
BASIC ELECTRICAL PARAMETERS
Electrical modalities parameters were developed to stimulate motor neurons leading to muscle contraction and large-diameter afferent neurons leading to pain relief. By varying the stimulus delivery, it has been shown in isolated nerve preparations that larger A afferent nerve or motor nerve fibers can be selectively stimulated over the smaller unmyelinated nocioceptive C fibers. Short-duration pulses activate large-diameter fibers, whereas longer duration pulses depolarize the smaller diameter fibers. For neuromuscular stimulation, a pulse duration of 0.1-0.5 ms should depolarize the motor fibers without activating the small nocioceptive fibers. Neuromuscular stimulation works best with intact peripheral nerves, in which the nerve depolarization can lead to full muscle contraction. Although laboratory studies of isolated nerve preparations demonstrate selective activation of large-diameter afferents over the smaller C fibers, in vivo fiber selectivity is unlikely. Stimulation through soft tissue to reach the nerve causes a nonuniform stimulation of the nerve, with more proximate fibers stimulated versus distal fibers. Electrical stimulation for pain control is rarely placed over a peripheral nerve in vivo. The large electrodes over the muscle belly can also lead to stimulation of the terminal axons as well as peripheral nerve trunks. Rectangular pulses and sine waves have also demonstrated selectivity in stimulation of different nerve fiber types. However, clinical in vivo application of the aforementioned factors has not been studied fully.
Common electrical definitions are reviewed here to allow the reader to understand better descriptions of clinically applied modalities described in later sections. The amount of current is responsible for physiologic effects caused by electrical stimulation. Most units are constant current applications varying voltage to changes in impedance. Direct current (galvanic) units cause a unidirectional flow that is continuous. Alternating current causes bidirectional flow (positive and negative), which can be balanced or unbalanced or symmetric or asymmetric. Pulsed wave stimulus is neither direct current nor alternate current because there is not a continuous flow. The stimulus is delivered in a series of pulses with a pause between pulses known as the interpulse interval. Pulsed forms can have variations in time-dependent parameters including phase duration and direction, pulse duration, interpulse interval, rise time, and decay time. Alternating current and pulse currents have frequency-dependent parameters including frequency of repetitions of the waveform or pulse and the period, which is the reciprocal of the frequency. All forms of current have the amplitude-dependent factor of peak amplitude. Pulse and alternating currents also may vary in peak amplitude of the phase, in peak-to-peak amplitude, and in phase or pulse charge, which is the area under the curve. Current modulations can also be applied and include amplitude, phase duration, pulse duration, frequency, and ramp (surge) modulations. Pulsed stimulus can be delivered in a train of repetitive, continuous pulses or in a burst fashion (interrupted train), with envelopes of stimulus separated by an interburst interval. Interferential current is a mix of alternating currents at different frequencies that are out of phase with each other. Table 1 compares different electrical parameters used in medicine.
Variations in stimulus parameters have a theoretical basis in type of fiber stimulated, better patient tolerance, and variations in segmental and suprasegmental pain responses. Although electric modalities have been used for more than 200 years, systematic study of the benefits of specific electrical parameters has not been done. Available data are reviewed in each section.
Electrodiagnostic (ED)
This method can define the functional state of muscles and nerves after the reaction on the dosed influence of electric current
Basic task ED to display complete or partial damage of nerve.
At the partial damage of nerve stimulation of muscle will be conducted through a nerve. At complete – directly through a muscle.
Apparates: КЕD-5, КЕD-5М, АСМ-2, АСМ-3, UЕІ-1
Button electrode
Another (non-active) plate electrode by an area 100-150 см2, locate between shoulder-blades or on a lumbar area, depending on localization of pathological processes . An active electrode is set on the motive points ( the Erba tables).
Placing of motive points ( from Erba tables )
In a norm the irritation of muscle by an impulsive current by frequency more than 20 Hertzs cause the tetanic contraction of muscle.
At pathology of muscle, but with the well-kept function of nerve its necessary greater strength of current.
At pathology of motive nerves a muscle loses ability to contraction under act of tetanic current.
Absence of excitability on both types of current testifies to the complete reaction of regeneration.
Electrostimulation (ЕS)
ЕS – applications of impulsive electric current in order to stimulate organs or systems activity.
It is administered only after 4 weeks from disease beginning (in absence of inflammation)
For ЕС the impulsive currents of rectangular exponential form with duration of impulses of 1-300 ms, and also alternating sinusoid currents are applied by frequency 2000-5000 Hertzs, which are modulated by low frequencies in a range 10-15 Hertzs.
At ЕS muscles the periods of rest are alternated with the periods of serve of series of impulses (rhythmic electro-stimulation).
Apparatus: СNІМ-1, “Аmplipuls“, “Stimulus-1”.
Placing of electrodes on a skin and description of current is set by a doctor-physiotherapy on the basis of information of electro-diagnostic research. The place of location of electrodes needs to be marked on a skin.
Stimulation of muscles of extremities, trunk, internal organs carry out by plate electrodes, and mimic – point (metallic plate by an area 1-2 см2, overturn by a matter) or quills electrode.
Electrostimulation of facial muscles
An active electrode (Cathode) is placed on the projections of motive points of the nerves and muscles indicated in the Еrba table. Another, nonactive (Anode) – between shoulder-blades or onlumbal, depending on localization of pathological processes ..
At the reception of procedure a patient must not feel the sickly or unpleasant feelings. Strength of current must not exceed 10-15 mА, duration of procedure -10-15 minutes. Course of treatment – 20-25 procedures.
Part of body, that is added to influencing, must be in comfortable position, that muscular contraction was well evident and took place without the obstacles.
Absence of contraction of muscles or sharp pain during conducting of procedure testifies to the wrong placing of electrodes, that does not coincide with motive points. In such cases conducting of procedure inadvisable.
Indications:
– paresises, paralyses
– muscular atrophy (after immobilization)
– atony of intestine, uterus, urinary bladder
Contra-indication:
– general
– spastic conditions of skeletal muscules and internal organs
– hysteria
NEUROMUSCULAR STIMULATION
Neuromuscular stimulation has been used in stroke and spinal cord injury rehabilitation to improve function. The bulk of the discussion focuses on the use of electrical stimulation in musculoskeletal injuries. Neuromuscular stimulation is used for overcoming reflex inhibition after an injury to allow the establishment of appropriate motor engrams. By programming appropriate engrams, the injured individual is less likely to use inappropriate muscle substitution patterns that may lead to future injury. Muscle stimulation also may be used to counteract immobilization atrophy, improve range of motion, break down adhesions in the muscle, and assist in relieving pain and muscle spasm. Athletic trainers may use muscle electrical stimulation at the end of a season to counteract fatigue and less voluntary effort during workouts. It has also been marketed for improving abdominal muscle tone without having to do situps. After nerve injuries such as brachial plexopathy from a football stinger, electrical stimulation has been used to maintain muscle viability.
Physiologic contraction of muscle occurs in a grade fashion, with the smaller, fatigue-resistant motor units type I, being recruited first followed by larger and larger motor units. With electrical stimulation, the larger diameter Type II fatigable fibers are recruited first. Muscle tension decreases as the fibers fatigue, unless the unit is turned up. Excessive fatigue can occur but can be limited by giving adequate rest periods between contractions and limiting the duration and frequency of the contractions. Criticism of the nonphysiologic muscle contraction produced by direct muscle electrical stimulation has led to a replacement of electrical stimulation with active assisted range-of-motion exercises by the athlete.
Electrical Parameters
Symmetric, biphasic square waveforms have demonstrated better patient tolerance compared with other waveforms. This waveform also allows generation of a larger muscle contraction compared to a monophasic waveform. Asymmetric, biphasic waveforms are used particularly with smaller muscles but have a greater incidence of burns and skin irritation owing to the accumulation of charge under one electrode. Amplitude intensity is set as tolerated by the patient up to 100 mA. The greater the intensity, the greater the force generated by the muscle contraction. Pulse duration varies from 0.2-0.4 msec and allows adjustment for patient tolerance when coupled with variable amplitude intensity. A pulse duration greater than 1.0 msec is associated with stimulation of pain afferents. Low frequencies are associated with incomplete muscle contraction. At 30 Hz, the muscle demonstrates tetanized contractions. Duty cycle is the ratio of on time (pulse train duration) to total time (on and off time) expressed as a percentage. For orthopedic problems, a 25% duty cycle has been suggested. If fatigue is a factor, then the duty cycle can be reduced. Most units have a ramp feature. Ramping is a parameter that allows a gradual increase to peak intensity that is over 2 seconds. After the peak amplitude is maintained for a specified period, the intensity is ramped down. This parameter theoretically allows an approximation of a normal muscle contraction and greater patient comfort. Indications and contraindications for neuromuscular electrical stimulation are listed in Table 2. Adverse reactions typically occur with skin allergies to the electrodes, mechanical irritation from the electrodes and occasionally itching or skin burn due to accumulation of charge under one electrode.
Clinical Uses
Neuromuscular electrical stimulation use is ubiquitous with musculoskeletal injuries in athletes. After an injury, pain and joint effusion can lead to inhibition or partial inhibition of muscular contraction. This is particularly common in the initial phases of rehabilitation. Muscles near the joint are more commonly affected. Electrical stimulation reduces edema, likely from muscular pumping action. Once acute swelling and severe pain are controlled, neuromuscular stimulation can be an effective muscle re-education tool. Atrophy can be minimized as well. Other uses are purported to decrease muscle and tendon adhesions, and scarring. Theoretically, if a muscle or tendons are strained, scar tissue develops as a part of the healing process. The athlete may perceive a feeling of pulling or tightness. Electrical stimulation in an isometric contraction purportedly allows the most muscle stretch and break up of the adhesions and scar tissue.
The effectiveness of neuromuscular stimulation in the prevention of postoperative atrophy of the quadriceps and hamstrings after anterior cruciate ligament reconstruction was studied. The subjects were randomized, although the actual randomization process is not well described. All three groups underwent early postoperative exercise training. The other two groups were treated with either TENS or a neuromuscular stimulator. Outcomes were measured by a blinded examiner and included isometric and isokinetic strength testing. Although the test was described as double-blinded, there were no sham units used, thus the study was single-blinded. Each group had 14-17 subjects. The researchers found no difference in strength between any of the groups. Power analysis was not performed. Thus, the lack of difference may be due to small sample size. However, this finding is consistent with other studies in healthy subjects using combinations of electrical stimulation and exercise. There were no significant differences in strength between voluntary exercise versus voluntary exercise plus electrical stimulation even at frequencies of 2500 Hz. Neuromuscular electrical stimulation has been effective in overcoming quadriceps inhibition in chondromalacia and subluxing patellae to facilitate a strength-training program.
Neuromuscular electrical stimulation has also been used recently in combination with TENS for pain control in chronic back pain. The combination reduced pain intensity, and subjects reported greater relief from pain compared with the use of either modality alone. All three treatment arms demonstrated reductions in pain compared with placebo. The placebo unit delivered no stimulus but had a functioning indicator light. Unfortunately, the study design was randomized repeated measures. Each subject experienced all four treatments, allowing possible unblinding of the placebo.
TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION
Physiology of Action
Our understanding of the pathophysiology of pain continues to evolve. The gate control theory developed by Melzack and Wall in the 1960s led to the development of the traditional parameters of high frequency stimulation in TENS units. The physiologic responses to TENS have been studied by measuring serum and spinal fluid endorphin levels, and by observing the effects of naloxone. In addition, the efficacy of TENS has been measured by alterations in pain threshold for various pain models. To assist the reader, a review of pertinent studies of TENS trials is illustrated in Table 3. The optimal parameters for electrotherapy remain unknown, although recent studies have shed some light. Controversy continues regarding frequency and intensity of the stimulus and the duration of treatment. It is not surprising given the current lack of knowledge that TENS units are likely used inappropriately.
Many studies have examined the frequency of stimulation as a factor of efficacy in the treatment of pain. Lower frequency stimulation allows for greater stimulation intensity. Initially, it was believed that these electrical parameters mimicked electroacupuncture. The low frequency likely stimulates small-diameter nocioceptive fibers and motor fibers. With low frequency stimulation, muscle contraction under the electrodes is seen and is believed to be a necessary component of effectiveness. Low frequency TENS is usually delivered at less than lOHz and more frequently between 2 and 4 Hz. The intensity of the stimulation is 0-80 mA. In experimental design, stimulation intensity is typically set at 1.5-5 times the perception threshold. The perception threshold is the first sensation of paresthesia. Studies have focused on endorphin responses found with low-frequency TENS. An increase in cerebral spinal fluid preproenkephalins after low-frequency TENS was demonstrated in subjects with a variety of neurologic disorders. Hughes measured an increase in plasma beta-endorphin levels iormal subjects after TENS. An indirect measure of endorphin activity is the effect of naloxone on pain relief with TENS. Trained pulses of 2 Hz stimulation were blocked by naloxone. In a rat arthritic model, analgesia was produced by 4 Hz TENS that was subsequently blocked by naloxone. The authors concluded the mu receptor at the spinal level was responsive to low-frequency TENS in rats. Another measure of efficacy in pain treatment is the analgesia produce with various experimental pain models, such as ischemic, mechanical, inflamed joints, or cold-induced pain models. In an ischemic pain model, researchers found TENS modified the pain response. A more specific study with the ischemic model demonstrated that low-frequency TENS at 4 Hz provided analgesia. In rats, the thermal threshold remained elevated for 12 hours after the application of TENS. High-frequency TENS modified pain responses to thermal pain, but not mechanical pain.
High frequency described as greater than 10 Hz was formulated from the gate control theory. Stimulation of large-diameter afferents should inhibit the second order neurons from carrying pain impulses from the small-diameter afferents. Thus, the small-fiber pain impulses never reach the brain. In groups of chronic pain patients or a variety of neurologic disorders, elevations of proendorphins, fraction 1 endorphins and substance P-like immunoractivity were found in cerebral spinal fluid. In human heroin addicts, lOO Hz TENS ameliorated withdrawal symptoms. Hughes also found elevations of plasma endorphins iormal volunteers after 100 Hz TENS. Animal studies using high-frequency TENS have demonstrated dose-dependent blockade of analgesia with naloxone. However, studies in humans with chronic pain did not find reversal with naloxone. Sluka has suggested that the dose of naloxone used in the aforementioned study may not have been high enough to block the endorphin receptors involved with high-frequency TENS. With an arthritic rat model, spinal delta opioid receptors were blocked with high dose Naloxone, reversing the analgesia induced by high-frequency TENS. Interestingly, blocking of kappa opioid receptors did not reverse the analgesia in either high- or low-frequency TENS. In a rat model of inflamed joints, the thermal threshold was elevated for 24 hours after TENS treatment, but there was no observable changes in joint behaviors. Human studies demonstrate similar effects. A double-blind, randomized controlled trial in healthy volunteers demonstrated significant increases in the mechanical pain threshold after 10 minutes of stimulation with TENS at 110 Hz. The effect peaked at 30 minutes and lasted for 5 minutes after the unit was turned off. Other studies also demonstrate that high-frequency TENS provides analgesia in mechanical pain models equivalent to 60 mg of codeine.
In 13 patients with hydrocephalus, Salar found a time-dependent response to high-frequency TENS stimulation. Cerebral spinal fluid beta-endorphins were measured at time zero, 20, 45, 60 and 90 minutes of treatment with TENS. They found beta-endorphin levels peaked by 45 minutes. Interestingly, persistent treatment of 90 minutes led to a return of endorphin levels to baseline. Unfortunately, there was no control group.
There are rare studies that examine parameters other than frequency of stimulation. An early study examined variations in stimulus intensity. Electroacupunc-ture has used high-intensity stimulation, 5-8 times the perception threshold. Sjol–und examined levels of analgesia produced by TENS application with burst stimuluation at 3-5 times the perception threshold. The researchers compared acupuncture like TENS with conventional high-frequency TENS delivered in a continuous fashion. Six out of the 10 with the low frequency, burst mode, and lower intensity demonstrated reductions in pain levels that were blocked by nalaxone. The high-frequency, continuous stimulation was not blocked by nalaxone. The lower intensity stimulus was better tolerated by chronic pain patients compared with higher intensity protocols. Walsh found no difference in pain reduction in burst versus continuous TENS. However, high-intensity TENS was more effective with continous stimulation, whereas burst was more effective with low-intensity stimulation for an ischemic pain model. Thorsteinsson and colleaguesfound placement of the electrodes is also an important factor of efficacy. Ieuropathic pain patients, stimulation directly over the involved nerve trunk provided great relief. In low-back pain, the stimulator gave significant improvement when placed over the center of the pain. This study also followed subjects for 6 months. Although subjects had an initial improvement in pain scores with TENS, 6 months later only 21/49 subjects continued to use the unit. Lack of analgesia was the most common reason for discontinuing the TENS. Thorsteinsson and associates emark that perhaps the initial reduction in pain was a part of the placebo effect. Unfortunately, TENS treatment was prescribed for only 20 minutes a session. The duration of treatment may have been too short to provide maximum analgesia with TENS. Another study looked at placement of electrodes over traditional Chinese acupuncture sites on the hand versus a control point on the hand. A combination of low- and high-frequency TENS was delivered for post-operative hemorrhoidec-tomy pain. The group with acupoint placement had lower pain scores and required less narcotic analgesic. However, 100 Hz TENS placement over auricular acupuncture points did not change electrical pain thresholds.
From the available data, TENS is likely to be most efficacious if a combination of low and high frequencies are used. The duration of treatment should be at least 30-45 minutes but should not exceed an hour. The intensity of the stimulus should cause tingling or tolerable muscle contractions. Placement should be over acupuncture points, the center of maximal pain, or over involved nerve trunks Based on their study and experience with TENS, Mannheimer and Lampe have recommended four stimulation modes for a variety of clinical scenarios. The conventional high-frequency TENS mode is the treatment of choice for acute, superficial pain associated with inflammation. For chronic inflammation or neurogenic pain, the acupuncture-like or low-frequency, high-intensity mode or the burst mode is recommended. When brief periods of analgesia are needed for painful procedures, the brief, intense mode can be used. Clinical evidence for these protocols is lacking.
Indications for TENS are listed later with the supporting evidence. Contraindications are noted by the Food and Drug Administration (FDA) to be (1) the presence of a demand pacemaker and (2) stimulation over the carotid sinus secondary to possible vagal responses of hypotension or cardiac arrest. Precautions issued by the FDA include (1) application in the abdomen or lumbar area during pregnancy; (2) application over the eyes; (3) application internally; (4) application transcranially or cervically in persons with a history of seizures, strokes, or transient ischemic attacks; and (5) application in cognitively impaired or children without adequate supervision. Adverse reactions to TENS have been reported primarily in the integumentary system. Allergic reactions to the electrode pads are the most common. The carbon-silicon pads can be substituted with a karaya alternative. Mechanical irritation to the skin from pulling of the pads has also been reported. Electrical burns under the electrodes due to poor or uneven skin contact have also been reported. Prevention of skin problems begins with clear instructions to the patient on proper electrode and tape use.
Acute Postoperative Pain
Carroll and associates published a thorough evidenced-based medicine review of the literature in 1996. They found 19 studies that provided appropriate randomization and controls. Fifteen of seventeenstudies found no benefit of TENS in treating acute postoperative pain. They also comment on the lack of blinding in the studies. With lack of blinding, an exaggerated positive effect of 17% would occur. Given that the studies should have an overestimation of the treatment effect of TENS owing to lack of blinding, the negative findings in 15 studies indicate that TENS is not an effective treatment in postoperative pain for the outcomes measured.8 Five of seven of these studies with an outcome variable of opioid consumption failed to find any significant difference with the use of TENS. Both positive and negative studies had subjects either titrate frequency or use a high-frequency setting.
In contrast, a recent double-blinded, randomized controlled report comparing low-frequency, high-frequency, and combination-frequency TENS treatment for postoperative gynecologic surgery indicated a significant 53% reduction in opioid analgesic use in the combined-frequency treatment group compared with a sham-TENS group. Low or high frequency alone reduced opioid intake by only 32% and 35%. The need for rescue medication was the same in all four groups, and the number of subjects who discontinued TENS was the same in all four groups. Power analysis was performed to detect a 30% reduction in opioid use. Interestingly, pain levels as measured by the VAS were not different between the groups. Thus, the patients did not perceive reduction in pain with the TENS unit but demonstrated a 53% reduction in the need for opioid analgesia delivered through patient-administered analgesia (PCA). The difference in this more recent study and the studies reviewed by Carroll and colleagues may lie in the method of opioid analgesia delivery. With PCA, the patient has relative control of the amount of analgesia delivered. In the studies reviewed by Carroll and associates with analgesia intake as an outcome variable, analgesia was administered by nurses in amounts dictated by the physician. Also, the prior studies used only one frequency of TENS, either high frequency or a titrated level determined by the subject. Perhaps, treatment with a combination of frequencies induces the most analgesia clinically. The clinical outcome of this recent study supports the results of the proposed physiologic responses of low- and high-frequency TENS on different systems in the pathophysiology of pain (mu versus delta opioid receptors). Based on the proposed mechanism of action of low- and high-frequency TENS on alternate sites in the pain pathway, this most recent study supports the need for further exploration of the clinical use of TENS in postoperative pain control.
TENS and Spine Pain
In acute low-back pain, there is conflicting information from randomized controlled trials of limited numbers regarding outcomes of pain reduction. One trial found no improvement in function. The other found improvements in range of motion. Conflicting data are also found in randomized controlled trials in chronic low-back pain. In a randomized, blind, controlled trial of exercise and TENS, 145 subjects with low-back pain of more than 3 months received treatment with sham TENS or TENS of 2 weeks of 80-100 Hz, 2 weeks of 2-4 Hz, and 2 weeks a frequency of their choice. The researchers found no difference between the TENS group and the sham TENS group but found improvements in pain and function in the exercise groups. Both the TENS and sham TENS groups had 42-47% improvement in pain indicators consistent with the placebo effect. A small placebo-controlled, double-blind study focused on a combination treatment of TENS with neuromuscular electrical stimulation (NMES), which causes actual muscle contraction. Individual and combined treatment led to improvements in pain intensity and VAS of pain in sufferers of chronic low back pain. The combined treatment led to the greatest improvements. However, the question of how truly blinded the sham treatments were perceived is suspect. Difficulty with blinding physical treatments remains a methodologic problem that these authors addressed as best as possible. In a nonblinded trial comparing acupuncture with TENS in elderly subjects with chronic low-back pain, both groups demonstrated pain reduction and medication intake that persisted at 3-month follow-up. The authors concluded that a placebo effect could not be ruled out for both treatment interventions. The Cochrane group analyzed trials of TENS and acupuncture-like TENS by evidenced-based methodology. They concluded that there is evidence from limited data that both TENS and acupuncture-like TENS are able to reduce pain and improve range of motion. However, other evidenced-based reviews have found no difference in pain, functional status, or mobility. In a nonrandomized, placebo-controlled trial in chronic low-back pain, high-frequency, low-intensity TENS provided pain relief in both the sensory-discriminative and motivational-affective components in the short term. Evaluation at 3 and 6 months did not show any benefit. The authors concluded that TENS may be a useful adjunct early in pain management but not over the long term.
Data regarding the use of TENS for cervical pain is even more limited. The Cochrane group evaluated the literature for the use of physical medicine modalities for mechanical neck disorders. There was not evidence to support electrotherapy in this population. However, they did cite two studies using pulsed electromagnetic fields that were proven effective. A miniaturized short-wave diathermy unit was built into a neck collar that the patient wore 8 hours per day for 12 weeks.
TENS and Obstetrics and Gynaecology
A systematic review of the literature found TENS to be of little use in relieving labor pain. Randomized trials were hampered by poor blinding techniques. They report that only three of eight studies demonstrated a positive result. The only study with appropriate blinding methods and with a positive result used a post-labor recall of pain score. The pain score was lower in the TENS group versus the sham TENS groups. However, in the pain scores taken during the labor were no different between the groups. A study using TENS to treat low-back pain specifically during labor found no difference between TENS and the standard treatment of massage and mobilization. Comparison of TENS to sham TENS yielded no difference in first-stage labor pain as judged by the amount of reduction in self-administered analgesia. All of these studies used a variety of frequencies, pulse durations, placement of electrodes, and duration of treatment, making comparison difficult. There is a suggestion that electrical stimulation can improve circulation. A recent Cochrane Review of the literature found no supporting studies for the use of TENS to improve blood flow in placental insufficiency.
In a cross-over design, women with dysmenorrhea were treated with 100 Hz TENS, Ibuprofen, both TENS and ibuprofen, or sham TENS (no electricity delivered). The subjects were not adequately blinded given a cross-over design. For the active TENS unit, subjects were asked to adjust the amplitude of stimulation to a comfortable tingling sensation. Thus, the subjects would be aware of a sham TENS that did not deliver electricity. Regardless, there were no significant differences in pain and symptom relief with TENS. Ibuprofen consistently improved pain measures. In a small study comparing intrauterine pressure, contractions and pain with dysmenorrhea, 12 women experienced significant relief with either naproxen or 70-100 Hz TENS with high amplitude (40-50 mA). Only the naproxen group experienced reductions in intrauterine pressure and contractions. Unfortunately, the study was not blinded.
A comparison trial of TENS alone, lignocaine injection alone, and TENS combined with lignocaine was performed for the treatment of pain related to cervical laser treament. TENS alone or in combination did not provide any analgesic effects compared with lignocaine. In a double-blinded randomized, controlled trial using a wrist-adapted TENS unit for the treatment of chemotherapy-related nausea, no difference was found in the intensity of the nausea or the percentage of persons with nausea. However, all subjects were treated with antiemetics, diluting the possible effects of TENS. Overall, further study needs to be conducted to determine whether certain stimulus parameters might benefit obstetric and gynecologic patients.
TENS and Urologic Uses
Application of TENS in the sacral region for detrusor instability led to a reduction in maximum detrusor pressure and an increase in the pressure at which the subject felt the first desire to void. Maximum cystometric capacity was unchanged compared with control subjects with sham TENS. A study with retrospective controls found pain reduced by 40% during lithotripsy with a TENS unit. Well-designed clinical trials are needed to determine the efficacy of TENS for this application.
In a study of subjects with classic and nonulcerative interstitial cystitis, TENS was helpful in reducing pain. Classic interstitial cystitis had a better pain response with TENS. In addition, many with ulcers present for greater than 10 years had healing of the lesion. For urologic patients, the optimal electrotherapy perscription has not been determined. However, it appears that sacral stimulation has effects on the detrusor muscle as well as an analgesic response.
Neuropathic Pain
Systematic study of electrical treatment of neuropathic pain is particularly sparse. Anecdotal reports have claimed benefit or lack of success. A double-blind trial in subjects with neuropathies demonstrated significant pain relief if the TENS unit was placed over the nerve trunk. There are some randomized studies using H-wave that demonstrate effectiveness in treating peripheral neuropathic pain (see later) . A pilot study looking at pulsed electrical stimulation delivered through a sock electrode overnight for a month reduced subjects’ 10-cm VAS. The study was not blinded or controlled.
In addition to reducing pain, electrical therapy may also improve peripheral circulation. A study used transcutaneous oximetry and laser Doppler flowmetry to study diabetics and controls before, during, and after electrical stimulation of the lower extremities. A transient, significant rise in tissue oxygenation was observed in the diabetics, but not the subjects without vascular disease. A study to determine whether electrical stimulation has any positive clinical effects from the change in perfusioeeds to be conducted.
Overall, further study needs to be done. Based on the limited data available it appears that electrical treatment of neuropathic pain may be a helpful adjunct for pain treatment. Possible perfusion effects may provide reduction or prevention of ischemic pain, but this needs rigorous study.
Cardiac Problems—Control of Angina and Postoperative Pain TENS is thought to reduce angina by two methods: first, by decreasing pain, and second, by reducing ischemia by improving myocardial oxygen consumption. Lactate levels, an indicator of ischemia, were lower with the use of TENS during atrial pacing in a group with severe angina pectoris. Over a 3-week treatment period, the number of anginal episodes and nitroglycerin use were decreased. A concomitant increase in work capacity was found compared with controls. An increase in coronary blood flow measured with intracoronary Doppler was demonstrated with TENS in fully innervated hearts. Increased blood flow in nonstenotic coronary arteries was demonstrated during high-frequency TENS stimulation in cardiac catheterization patients. Post-cardiac bypass surgery subjects using a pulsed form of TENS had reduced pain levels compared with controls. However, no difference was found between TENS and placebo TENS groups. No differences among the groups were found with outcomes of pulmonary function and narcotic intake. Again, specific parameters need to be studied systematically. The effect on circulation is important. More clinical studies are needed once the optimal electrical parameters are established.
Pediatric Uses
In a well-designed study of TENS and sham TENS compared with a control group of usual care, children of all ages felt improvement in pain during vena-puncture with the TENS. Although the sham TENS group had reduction of pain compared with the control group, the TENS unit group had the greatest reduction. A case series of children with reflex sympathetic dystrophy and the use of TENS reported improvement in symptoms. The lack of controls, however, indicates that there is little definitive conclusions that can be drawn from this report.
Other Musculoskeletal Pain
There is surprisingly little study of other musculoskeletal pain syndromes beyond spine pain In a group of subjects with frozen shoulder, a randomized controlled trial compared high- and low-frequency TENS with placebo. Both TENS groups had significantly lower pain levels postprocedure compared to controls.
Gastroenterologic Uses
A study focusing on the correlation of esophogeal distension and chest pain found reduction in pain and esophogeal peristaltic velocity with the use of high-frequency TENS of moderate intensity (20-30 mA) and 0.2-msec pulse duration. In a nonblinded, randomized, controlled trial in subjects undergoing hemor-rhoindectomy, TENS stimulation at a traditional Chinese acupuncture point compared with TENS stimulation on a control point yielded pain reduction when stimulated at the acupuncture point only.
ELECTRICAL ACUPUNCTURE
Researchers in China have demonstrated in rats and humans that electro-acupuncture at the 100-Hz level blocked morphine withdrawal. A high dose of naloxone was able to block the electroacupuncture response in rats, implicating the kappa opioid receptor. In addition, spinal levels of dynorphin A, an endogenous opioid peptide, returned to normal levels after stimulation with electro-acupuncture.
Out of five studies reviewed with evidenced-based medicine principles by the Cochrane collaboration, only one generated a positive result. This study used a combination of low- and high-frequency stimulation. Improvements were demonstrated in pain description, global improvement scale, and a VAS for function. The improvements seen compared with wait list controls were maintained 6 months later. The other four were neutral owing to methodologic problems. There were no standard electrical parameters, and studies varied in choices of intensity, frequency, and placement. There are interesting effects with spinal opioid levels demonstrated with electroacupuncture. Future research likely will focus on optimal electrical parameters for maximal analgesia in the clinical setting.
Percutaneous Electrical Nerve Stimulation
In percutaneous electrical nerve stimulation (PENS), needles are placed through the skin into soft tissue or muscle at various sites and electricity is applied through the needles. It is believed to be a combination of TENS and electrical acupuncture. With standard electrical parameters, research with PENS has been beneficial owing to the ability to compare responses in multiple studies.
In a randomized, single-blinded, cross-over study in patients with chronic low-back pain from degenerative disk disease, PENS reduced pain, improved function, and led to a reduction in opioid analgesia compared with the use of needles alone (sham PENS), TENS, or an exercise program (of questionable merit-seated flexion and extension exercise). Reduction on VAS of 82% was demonstrated in the PENS group, whereas the sham PENS, TENS and exercise reduced pain by only 4-26%. Their randomization procedures were not described. Bias was likely, with subjects acting as their own controls. In a single blind study, observer bias is likely as well. The same design was applied to a group with sciatica from a herniated disk lasting more than than 6 months. Similar results were found as in the degenerative disk group. Another randomized single-blinded study with PENS and sham PENS in persons with chronic low-back pain, treatment with PENS for more than 30 minutes improved short-term VAS pain scores, oral analgesic use, physical activity, and sleep. Again, how well the subjects were blinded is questionable, and a cross-over study is not the ideal design to minimize this methodologic error. Further study by this group of researchers, using cross-over design found 15-30 Hz to be the frequency of PENS leading to the greatest improvements in decreasing pain, and increasing physical activity and sleep.
A single-blind, randomized study of PENS in postherpetic neuralgia demonstrated reductions in pain at 3 and 6 months but not 9 months. Unfortunately, statistical analysis was not reported in the long-term component of the study. Better-designed clinical studies need to be performed for both electroacupuncture and PENS.
H-WAVE
The FDA has approved the H-wave muscle stimulator for relaxation of muscle spasm, prevention of retardation of disuse atrophy, edema control, muscle reeducation, prevention of postoperative venous thrombosis, and in maintaining or improving range of motion. Low-frequency settings are used for muscle contractions, whereas the high frequency is used for pain relief (Electronic Waveform Lab, Inc). A larger unit is used in clinical practice, whereas a smaller home unit can be obtained for the patient. The unit is not designed for full portability.
In a double-blind, randomized controlled trial measuring the effect of H-wave stimulation on the mechanical pain threshold (MPT), H-wave caused significant increases in the MPT after 10 minutes of stimulation and peaked at 30 minutes. The increased MPT lasted up to 5 minutes after the H-wave stimulation was completed. These effects were similar to the analgesia provided by a comparison group using TENS. Another study demonstrated similar improvements in MPT with 2-, 16-, and 60-Hz H-wave stimulation (McDowell). However, ischemic pain models did not demonstrate an analgesic effect of H-wave. This finding contradicts an earlier study demonstrating the effectiveness of H-wave therapy with 60-Hz stimulation in relieving ischemic pain. However, this study was only single-blinded compared with the later study. Thus, H-wave is not likely beneficial in ischemic pain.
Two randomized and controlled trials in diabetics with peripheral neuropathy demonstrated reduction in overall pain scores (0-5) and analog scores for symptoms. Patients used a home unit 30 minutes a day for 4 weeks. In the later study, a group was chosen that was refractory to amitriptyline. In both studies, a small subgroup demonstrated 100% relief in pain. Conflicting data and poorly designed studies indicate that further study is needed.
CODETRON
Codetron delivers electrical stimulation similar to traditional a TENS unit but randomly switches stimulation between the six electrode sites every 10 seconds. The theory is by frequent changes in stimulation sites, habituation from repetitive signals is avoided. In a blinded, randomized, controlled trial of 58 subjects with acute occupational low-back injuries without objective spine pathology, Codetron offered no improvement over placebo in functional status, perceived pain, or return to work. In 36 osteoarthritis subjects randomized to either codetron or sham Codetron, no improvements in 50 feet walking time, joint line tenderness, range of motion or knee circumference were found. Pain measures using the 10-cm VAS and the West Haven Yale Multidimension Pain Inventory did demonstrate significant improvements in the Codetron group. However, randomization and blinding procedures were not well described. No other randomized, controlled trials were found by Medline search from 1966 to present.
INFERENTIAL CURRENT THERAPY
Inferential current is medium frequency (4000 Hz) amplitude modulated at a low frequency of 0-250 Hz. It is produced by mixing two out- of -phase currents (2000 Hz and 4000 Hz). It was developed to reduce skin resistance and allow amplification in the tissue. The current that reaches the tissue should be an average of the two frequencies, and the amplitude-modulated frequency is the difference between these two delivered frequencies The medium frequency is viewed as a “carrier” frequency for the lower frequency generating clinical analgesic effects. A study focusing on the analgesic effects of inferential therapy found that the amplitude modulation did not change the response compared with nonamplitude modulation. The purported benefit of interferential current therapy over TENS is a more rapid onset of analgesia within 15 minutes. The effects are likely similar to low-amplitude, burst-mode TENS.
Although interferential current electrotherapy has been used in several countries, clinical trials are rare. The reader is referred to several reviews regarding various electrotherapies. A randomized, controlled trial in the Netherlands compared interferential therapy with ultrasound in the treatment of shoulder pain. A control group allowed exercise therapy alone without adjuvant treatments. Each electrotherapy group had a subgroup of sham therapy. In the interferential therapy group, the sham therapy group received a few minutes of electrical stimulation, three times over a 15-minute period. The treatment group received continuous interferential current for 15 minutes. Patient perception of recovery and physical therapy evaluation translated into VASs were the measured outcomes. No differences were found among any of the five groups. The authors concluded that ultrasound and interferential current therapy are not efficacious for the treatment of shoulder pain. Other reports of interferential therapy describe benefits in the treatments of urinary stress incontinence, osteoarthritis, jaw pain, and to promote fracture healing. Randomized, controlled trials supporting the use of interferential therapy are lacking.
Interferential current therapy uses a novel approach to allow greater stimulation to bypass skin impedance. The relative benefits have not been proven by well-designed, randomized, controlled trials. Initially, the units were bulky and limited to physical therapy practices. Now small units are available for home use. The reimbursement rates are similar to a TENS unit (data from TENSPEDE). More randomized, controlled trials are needed to understand better the role interferential therapy plays in physical medicine and rehabilitation practice.
SUMMARY
Although clinical claims of efficacy have outpaced our understanding of the underlying physiologic mechanisms of electrotherapy, new evidence indicates that electrotherapy has effects on spinal cord opioid systems. The optimal parameters for application of electrotherapies remain to be determined. The potential benefit of a nonpharmacologic treatment for patients with pain demands rigorous pursuit of increasing our understanding of electrotherapy.
Acupuncture in the Management of Neuromusculoskeletal Disorders
Acupuncture has been used in traditional Chinese medicine to relieve pain and cure a variety of diseases for more than 2500 years. The ancient Chinese were aware of an increased sensitivity of certain skin areas (called acupoints) when an organ or function was impaired. Through experience, 361 acupoints were gradually identified to form a network of 14 channels, called meridians. The whole system of meridians brings about the integrity of the body by connecting the internal organs with the superficial parts of the body.
Acupuncture was introduced to the West by Jesuit missionaries to Peking in the 17th century. In the 1930s, de Morant reintroduced acupuncture to France, and the rest of Europe soon became interested, developing research programs to study its clinical applications. Since then, research has confirmed that acupuncture therapy produces an analgesic effect through noxious stimuli that induce endogenous pain relief substances. Animal experiments verified the positive effects on the circulatory, digestive, and urinary systems and for epilepsy control.
The interest in acupuncture is growing in the United States, Europe (especially France, Italy, the United Kingdom, Germany, Russia, and some Eastern European nations), and Argentina, but it also has been the object of scientific study in East Asia (China, Japan, and Korea). Acupuncture was brought to the attention of American medical professionals in 1971 when James Reston reported that acupuncture analgesia relieved postappendectomy complications he suffered in China. Dr. Howard A. Rusk also expressed interest in acupuncture research in the preface of his textbook Rehabilitation Medicine.
A World Health Organization (WHO) interregional seminar drew up a provisional list of 47 diseases that are amenable to acupuncture treatment. Of these 47 disease, 16 are neuromusculoskeletal disorders. Learning acupuncture may be simplified by limiting its use to therapy for neuromusculoskeletal disorders rather than for all fields.
THE SCIENTIFIC BASIS OF ACUPUNCTURE POINTS
Acupoints can be easily determined by anatomic landmarks or by the measurement with subject’s own hand or finger called “own body scale.” In 1950, Nakatani found that the electric impedance at an acupoint is 1/20 to its surrounding skin area, an area that is easily measured with a simple impedance detector.
Acupoints have been reported with different sizes, from small points to large areas (100-400 um), and are located subcutaneously, intramuscularly, or in the viscera. Nearly all of them are closely related to nerves, and 84.36% of them are near blood vessels. Local infiltration with an anesthetic agent blocks the effect of acupuncture analgesia only when the anesthetic is injected to a certain depth,
Other than the 361 classical acupoints, other groups of acupoints exist that are effective in treating particular symptoms. They were named in Chinese in accordance with their position or function. The Chinese names are easier to remember than their English translations, but the difficulties in proper translation may be overcome by readily available commercialized computer programs. Another group of acupoints, called Ah’s points (remembered by the phrase “Ah yes, this is the trigger point”), have the same characteristics and locations that are similar to the trigger points of myofascial pain syndrome, but were discovered independently and labeled differently.
NEUROMODULATION OF ACUPUNCTURE
The word acupuncture is derived from two Latin words, acus (“needle”) and punc-tura (“puncture”). However, the structure of an acupuncture needle differs from the ordinary injectioeedle in its fineness (gauge 30-36) and in its blunt tip, which separates the tissue rather than sharp cutting during twirling.
The characteristic sensation of acupuncture needling, which is called de qi, is a prerequisite for effectiveness . It can be evoked only with puncturing and twirling at the acupoint. In general, the manual needling evokes activity in type II and type III fibers . Electrical acupuncture stimulation mainly excites type II fibers. Type III and IV fibers might be excited when heavy needing techniques are applied, which may cause resultant occurrence of pain.
The sensations evoked by acupuncture applied to points on a limb to be amputated were recorded by Lu and colleagues and Lin and associates. In general, sensations described as “numbness” are evoked by direct stimulation of nerves, and “soreness” by needling tendons or periosteum. “Heavy” or “numb” sensations are Acupuncture in the Management of Neuromusculoskeletal Disorders 229 evoked by acupuncture stimulation of muscles, whereas pain is altered when perivascular nerve filaments are stimulated by acupuncture. The propagated sensation according to Cajal is a quasi-nervous structure that entwines blood vessels and is related to the neurilemma or the sheet of Henle.15c It is believed to be related to the sympathetic innervation of skeletal muscles. Another possibility is that propagated sensation is the result of processes similar to the spread of excitation in the central nervous system.
The development of electroacupuncture provides good effect on pain control and muscle stimulation . The use of skin electrodes at the acupoint has increased public acceptance in recent years. With surface electrodes, the side effects of acupuncture including local pain, hemorrhage, infection, pneumotho-rax, broken needle, and syncope (0.2% incidence) can also be avoided.
ACUPUNCTURE FOR MUSCULOSKELETAL INJURY OR DISORDERS
The Hegu (LI4) is a point located at the junction of the proximal end of the first and second metacarpal bones, with good general analgesic effect for fascial pain, Yanglingquan (GB34) is located on the depressed area lateral to the tuberosity of the tibia with the knee flexed 90° It is a very good acupoint for muscle relaxation, which is indicated for traumatic injuries.
Sanyanglo (T8), which is located at the lower third of the forearm on the extensor side between the radius and ulna, is good for treating chest pain, intercostal neuralgia, and pain in the upper extremities.
Huantiao (GB30) is located at the lateral one third of the gluteus maximus, between the greater trochanter of the femur and coccyx . At 3 or more inches, this is the deepest acupoint. This point is effective for treating back pain and sciatica.
Weichung (B54) is located right in the middle of the popliteal fossa . Needling this point treats lumbago, sciatica, leg muscle cramp, and knee stiffness.
Tiaoshan, located at the midpoint of the tibia one of the lateral aspect, is penetrated from Tiaokou (ST38) to the back of leg at Chengshan (B57) for 2-3 inches . Shoulder pain and acute frozen shoulder can be treated using this acupoint.
The pair of acupoints known as Yaotiew (Ex-UE7) is located at the proximal end in between the second and third metacarpal bones and the fourth and fifth metacarpal bones . These points are effective for lumbar strain, lumbago, and sciatica. Acupuncture had been reported to be very effective in acute soft tissue injuries, with excellent results in 71.5% of the patients, 18.9% with good results, and 9.6% with fair results. However, in chronic soft tissue injuries treated with acupuncture, only 34% of the patients achieved excellent results, 29.3% achieved good results, 27.8% reported fair results, and 9% indicated a poor grade. The author stressed that this phenomenon may be considered important for the attenuation of pain. It has the benefits of noninvasive and better patient tolerance. It is suitable in treating athletic injuries on both body acupuncture and ear acupuncture, especially in combination with an acupoint detector. Some chronic painful conditions including myofascial pain syndrome can be treated by acupuncture in Ah’s point (trigger point), commonly seen in the management of sport injuries.
ACUPUNCTURE FOR OSTEOARTHRITIS
Acupuncture is a common alternative to medication in the treatment of osteoarthritis (OA). The long-term effect of acupuncture treatment was studied in patients with OA of the knee. Significant reductions of pain and analgesic consumption in the treatment were noted by comparison with the control group. However, a randomized, placebo-controlled study involving 40 patients with OA of the knee showed that both real and sham acupuncture significantly reduced pain, stiffness, and physical disability, but no difference was found between the two groups.
The common acupoints for OA are selected from the points near the joints. For instance, GB34, GB33, SP9, and SP10 for knee OA and SI6 for wrist OA and the multiple OA joints are suggested.
ACUPUNCTURE FOR PAIN CONTROL
Acupuncture and electroacupuncture effects are mediated through a variety of neural and neurochemical mechanisms. Research done in the early 1970s first elucidated the mechanisms for the effect of acupuncture anesthesia. Experiments in rabbits showed that this effect can be transferred from one rabbit to another by cerebrospinal fluid (CSF) transfusion. More recent investigation explored the role of classic central neurotransmitters in the mediation of acupuncture analgesia, including catecholamines and serotonin. The availability of rat models for electroacupuncture, using the tail flick latency as a bioassay, allowed further experiments done to explain the basis for the effect. Differential release of central nervous system (CNS) opioid peptides by electroacupuncture has been noted, with 2-Hz of electroacupuncture triggering the release of enkephalins and beta-endorphins, and a 100-Hz stimulation selectively increased the release of dynorphin in the spinal cord. A combination of both frequencies allows synergistic interaction among the three endogenous opioid peptides and provides a powerful analgesic effect. In addition, multiple acupuncture treatments with the optimal time spacing may result in an accumulation of electroacupuncture effect. A bimodal distribution of analgesic effect can be noted if a large group of rats is given electroacupuncture (low responders and high responders). Low response is caused by at least two mechanisms: a low rate of release of opioid peptides in the CNS and a high rate of release of cholecystokinin octapeptide (CCK-8), which exerts potent antiopioid effects. A newly discovered antiopioid peptide, orphanin FQ, has also been linked to negative feedback control of electroacupuncture stimulation.
ACUPUNCTURE FOR PHANTOM LIMB PAIN
Acupuncture therapy for phantom limb pain of amputees may stimulate large sensory afferent fibers and suppress pain perception as explained by the gate control theory of pain. The needle insertion may act as a noxious stimulus and induce endogenous production of opiate-like substances to effect pain control.
In the patient with single-limb amputation, acupoints in the intact, contralateral limb that correspond to or near the painful areas may be used in the perceived phantom limb every day or every other day. In patients with bilateral amputation of lower limbs, the acupoints of the intact upper limbs can be used as reference points to treat patients (e.g., elbow for knee; wrist for ankle). Remarkable reduction of pain scores and shortening of the most severe phantom pain were reported, although these results do not appear to alter the final outcome in the pain score or the duration of phantom limb pain.
With single photon emission computed tomography (SPECT) study, phantom limb pain was possibly associated with cortical activation involving the frontal, temporal, or parietal cortex. Hypoperfusion of bilateral thalami and brain stem was observed after acupuncture therapy.
ACUPUNCTURE FOR STROKE THERAPY
Acupuncture may be enhanced by the functional plasticity of the brain. A study with real versus sham acupuncture in the treatment of paralysis in stroke patients indicated that a significantly greater number of patients had a good response to real acupuncture than sham acupuncture at various lesion sites based on CT scans. Studies on functional reorganization after stroke using positron emission tomography (PET) suggest that considerable reorganization within the brain occurs after stroke, including metabolic activation of contralateral and frontal areas. Acupuncture in the Management of Neuromusculoskeletal Disorders Many studies report that acupuncture treatment for stroke patients can produce beneficial effects on motor function recovery, reduction of spasticity, and improvement of poststroke depression. Decreased ankle spasticity and improved gait cycle parameters have been reported after acupuncture therapy in older patients. The H-reflex recovery time of the paretic side of chronic stroke patients is significantly prolonged after acupuncture therapy.
The use of electrical acupuncture through adhesive surface electrodes on GB21, TZ14, LI10, and LI4 in the upper extremity and ST32, SP10, GB34, and Liv3 in the lower extremity help achieve a better functional outcome in stroke patients and shorten the hospital stay for rehabilitation. It can be applied during the acute stage of stroke without the side effects of needle acupuncture, even in patients who underwent anticoagulation therapy.
ACUPUNCTURE FOR SPINAL CORD-INJURED PATIENTS
The animal experiment of first aid acupuncture treatment in spinal cord-injured (SCI) rats at B160, B154, and GV3 within 15 minutes after surgery was accompanied by minimization of post-traumatic cord shrinkage and a marked sparing of ventral horn neurons. Human clinical studies also show remarkable improvement of spinal paraplegia with acupuncture therapy in 120 patients.
Therapeutic trials of acupuncture therapy for neurogenic bladder of SCI patients at CV3, CV4, and bilateral UB32 , in addition to conventional intermittent catheterization program (1CP), showed significantly shortened duration for bladder training. There was no difference in duration in treating the neurogenic bladder of upper or lower motor neuron lesion.
NEURAL BASES OF ACUPUNCTURE STUDIED BY FUNCTIONAL MAGNETIC RESONANCE IMAGING OF THE BRAIN
Modern advanced brain imaging such as functional magnetic resonance imaging (fMRI) and PET of the brain has been successfully applied to the study Location of the acupoints CV3, CV4, and UB32. A, Anterior view. CV4 is located on the midpoint from the umbilicus to the symphysis pubis. CV3 is located on the upper one-third from CV4 to the symphysis pubis. B, Posterior view. B32 is located at the interver-tebral foramen between S2 and S3 acupuncture. Many scientists believe that the main thrust of acupuncture may be in the brain. The activation result of acupuncture stimulation of acupoint GB37 (vision-related disease treatment) showed nearly the same result of the direct visual stimulation by an increased signal in MRI. Similarly, for ear or hearing-related acupoint SI5, a similar result of cortical activation pattern of acupuncture stimulation followed closely that of direct auditory stimulation with music. It might support the hypothesis that acupuncture stimulation of a specific acupoint could deliver information to the corresponding cortical area or areas, thereby activating higher centers of the brain to make necessary alterations to balance hormonal, autonomic nervous systemic, and neurochemical activity.
OTHER TYPES OF ACUPUNCTURE
Scalp Acupuncture
Acupuncture applied to the scalp was developed by the Chinese neurologist S.F. Chiao in 1970. He treated brain injury patients with motor paresis or paralysis by inserting needles into the scalp according to the referral area of Brodmann .
Vaso-dilatation in cerebral vessels and an increase of cerebral blood flow were proved by transcranial Doppler sonography in some stroke patients but not in a normal control group. It is used in the treatment of cerebro-vascular accident (CVA), head injury, cerebral palsy, and hyperactivity and psychic disorders.
Auricular Acupuncture
In the traditional Chinese literature, scattered statements about ear acupoints can be found, but no meridian specifically is noticed among them. Around 1956, reports appeared both in China and in France that the diagnosis and treatment of some diseases could be attained through needling or stimulating specific points on the auricles
Auricular acupuncture can be performed by a small needle (1 mm long) with a ring tail, held in place by tape for 1 or 2 weeks at the ear acupoint. It has better clinical convenience for chronic soft tissue pain and may be applied as an adjunct in the treatment of myofascial pain syndrome. It is also used for treating cerebral palsy
