Electrotherapys Role in Pain

Management
Philadelphia 2004
Joseph A. Gallo, ATC, PT
Associate Professor
Hesser College
Applied Medical Sciences
Clinician Performance Rehab

Workshop Agenda
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Electrotherapy for
pain: why use it?
General
electrophysiology a
practical review
Waveform principles
Clinical Selection of
waveforms and
parameter settings

Introduction
z Why

the interest in electrotherapy???

z Why the confusion???
z Importance of terminology
z The Parameters
z Why treat the pain impairment???
Fundamentals
we can only build as high as our foundation is deep - unknown

The pain Impairment

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What is pain?
What Physiologic and psychological effect does it
have on our patients?
Inhibition of muscle
Lack of confidence, tentativeness, depression
Poorly managed acute pain can lead to chronic
pain, chronic inhibition of mm, disuse atrophy and
contracture

Concepts Related to Pain

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Subjective response
Central Biasing
Psychosocial component of pain appears to be
accentuated when other life stressors are
predominate
Role of positive belief systems and attitude
Ethnicity1

1. Zborowski M: People in Pain. Sanfrancisco, Jossey-Bass, 1969

Treating Pain: The Controversy

Argument #1
Using passive modalities to treat pain is of
no use; the cause of the pain must be
identified and resolved
Argument #2
Pain interferes with treatment of the
underlying pathology and if left untreated
can lead to further dysfunction

Assessing Pain

Pain assessment is critical to assessing the

effectiveness of electroanalgesia treatments
Numeric pain scale (NPS) 0-10
High test retest reliability (ICC = .96)1
Strong correlation to VAS (r=.85)2
Visual analogue Scale (VAS)

1.

Ferraz et al. J Rheumatol. 1991;18:1269.

2.

Paice et al. Cancer Nurs. 1997;20:88-93

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Assessing Pain Continued

z Body

Pain Diagram
z Mcgill pain questionnaire
z Interview/history/symptom behavior

Pain/Inflammatory Cycle

Neurobiology of Pain

Electrotherapy and Pain

Control
z Theories

of pain
control using
electrotherapy
Gate Control

Theory
Opiate-mediated
Control

Gate Theory of Pain Control

z Melzak

and Wall 1965

z Substantia Gelatinosa and T-cell (dorsal
horn of SC) controls nerve impulses to
the brain. Only allows one impulse
through at a time; like a gate.
A-delta afferents fast pain 4-30 m/s
C- fibers slow pain 0.5 -2 m/s
A-beta afferents pleasant/fast 36-72 m/s

T-cell

Pain
Sensory

Motor

Brain

Opiate-Mediated pain Control

Descending endogenous opiate system

Supraspinal pain modulation that produces a descending
inhibition of pain chemically at the dorsal horn of the spinal
cord
The spinal gate is closed from influence from above
The periaductal gray matter secretes endogenous opiates
in the blood plasma and cerebral spinal fluid
Endogenous opiate peptides - enkephalins, beta-endorphin
Endorphin means Morphine Within longer lasting
pain suppression
Enkephalin means Within the Head shorter acting
pain suppression

Opiate-Mediated pain Control

Chronic pain patients have been found to have

below normal levels of endorphins in their
cerebral spinal fluid
Endorphins have been shown to increase in the
cerebral spinal fluid with twitch level electrical
stimulation.
Goal of electrotherapy is to boost the levels of
Endorphins in a patient

What is Electrotherapy?
z It

is the application of electrical stimulation

transmitted through the body via electrodes
for therapeutic purposes.
z The current flows through the body from
one electrode to the other and causes
different physiological reactions depending
on the type of current selected, the
parameters of the selected current.

Review of Electrotherapy
Currents: Yes! It Is This Simple

Electrotherapy Currents
Pulsed Current

Alternating Current

Direct Current

Pulsed Current

Alternating Current

Direct Current

Selecting Electrotherapy
Parameters: Terminology
z Electrotherapy

is about building pulses

(PC) or cycles (AC)
z The ht (amplitude), Width (phase or cycle
duration), and frequency are maniplulated
to create a desired physiologic response

Pulse (PC) and Cycle (AC)

Characteristics
z Amplitude:

(intensity) mA = how tall

z Width: microseconds
Phase duration (Pulsed current)
Cycle duration (alternating current)
Carrier frequency of 2500 Hz = 400
microseconds
Carrier frequency of 5000 Hz = 200
microseconds

Strength Duration Curve: the basis

for selection amplitude and width

Frequency
z Refers

to how many times per second the

pulse or cycle is delivered
z Termed beat frequency when AC is used
z Difference between carrier frequency and
beat frequency

Carrier frequency indirectly describes cycle

duration

General Electrophysiology
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Clinical Stimulators
Patients tissue

Generic Stimulator

completes an electrical
circuit
The lead wires carry the
current from the
stimulator through the
electrodes to and
Anode positive pole
Cathode negative pole
through the patient
+
Skin is a resistor
impeding current flow
Generic Patient
Subcutaneous tissue is a
conductor

General Electrophysiology
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Target Tissue

Generic Stimulator

Sensory, motor, or pain nerve

fibers

The current flows through

the target tissue to the other
electrode and up the other
lead wire to the stimulator

Generic Patient
The patient completes the circuit

Electrode Issues
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Electrodes should be
placed so the flow of
current can reach the
target tissue
The farther apart the
deeper the penetration
Placed too close the
potential exists for
greater concentration
Superficially this can
result in discomfort

Choosing appropriate electrode

size
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Small electrode
(ex: 2 x 2 inches)
Increases current
density
Recruits fewer motor
units
More uncomfortable

Large electrode
(ex: 4 x 5 inches)
Decreases current
density
Recruits more motor
units
More comfortable
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Electrode Skin Interface

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The skin is a resistor to

the flow of current
Good skin preparation is

important
To lower impedance clean
the skin (alcohol or soap)
Proper electrodes and
conductive medium are
essential
Pearls and pitfalls

Electrode Placement
Strategies For Pain
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Bracket structure
a. Proximal / Distal
b. Medial / Lateral
c. Anterior / Posterior
Directly over the site of
pain
Interferential is a quad
polar (4) electrode
application. The area
should be bracketed X.

Bi-polar placement

Electrode Placement
Strategies Cont..
Structure and
Innervation
a. Major nerve root
b. Dermatome
c. Superficial
peripheral nerve
d. Acupuncture and
trigger points

a
b

Quad-polar placement

Literature review of applications: USA

Application
Pain Management
Acute
Chronic
Spasms
Post-Operative
Muscle Weakness
Min to moderate
Moderate to Sever
Disuse Atrophy
Re-education
Increase ROM
Prevent Venous
Thrombosis

IFC

Premod

VMS

HVP

yes

Inflammation / Edema
Increase local
circulation
Tissue healing
Spasticity
management
Contracture
management

MicroCurrent

Russian

Three Categories of
Electrotheraputic Currents
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Direct Current:
Historically refereed to
as Galvanic Current
involves the
+
continuous or
0
uninterrupted flow of
charged particles.
Clinical apllications
Iontophoresis
Stimulating denervated

muscle

Direct Current

Alternating Current
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Historically referred
to as Faradic
Current involves the
continuous or
uninterrupted bidirectional flow of
charged particles.
Interferential

Stimulation
Premodualted
Russian

Beat Frequency: 100 Hz

Pulsed Current
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Pulsed or interrupted
current is an isolated
unit of uni- or bidirectional movement
of charged particles
that periodically ceases
for a finite period of
time.
Twin Peak High Volt

Pulsed Current
Monophasic, biphasic
VMS, Microcurrent,
Common TENS, Low
Volt

Waveforms: various
configurations of the 3
electrotherapy currents
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High Volt Pulsed current

Biphasic
VMS
Premodulated
Interferential
Russian
Microcurrent

High Voltage Pulsed Current

z High

Volt current is a rapid succession

of two brief high voltage impulses. The
current flows in only one direction,
which is determined by the selection of
either a positive or negative polarity
setting.

VMS
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VMS a
trademarked name
of the Chattanooga
Group
Variable Muscle
Stimulation
Symmetrical

Biphasic Square
Waveforms with a
100 mSec interphase
interval

Premodulated
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The two medium

frequency sine
waves are mixed in
the system and
delivered to the
patient with two
electrodes.

Premodulated Current

Beat Frequency: 100 Hz

Premodulated Current is simply taking two alternating
medium frequency currents mixed within the electronics of the unit
and delivered through two electrodes.

Clinical Benefits
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Comfortable
Simple two pad
setup
Easily applied to
small joints of the
upper extremity
Acute or chronic
pain

Interferential
Quad-Polar
z Alternating

Current
z Continuous medium-frequency sine wave
z Uses two channels of differing carrier
frequencies to create a beat frequency
within the tissues.
Scan - amplitude modulation
Sweep - frequency modulation
Intensity - output amplitude

Interferential
Channel 1

5,000 Hz

Channel 2
5,100 Hz

Interferential Characteristics
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Amplitude modulated, medium frequency, sine wave

Interferential Current is simply taking two channels of
alternating medium frequency current and arranging the electrodes in
a crossing pattern.

Ch. 2

Ch. 1

Ch. 1

Ch. 2

Clinical Benefits
z Comfort
z Targeting

hard to
reach tissues (e.g.subscapularis)
z Pain modulation
Acute
Chronic

Acute or chronic pain

Russian
z Characteristics
Sinusoidal alternating current with a 2,500

Hz carrier frequency.
Current modulated at 50 Hz
2500 Hz

Burst

Microcurrent
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Subsensory level
Microcurrent wave
forms vary btwn
manufacturers
Pulsed current
Alternating current
Low intensity direct
current

Clinical Decision Process: choosing a

waveform to meet your objective

Concept: the waveform

is not the treatment
We use waveforms to
deliver a specific
electrotherapy
intervention (e.g. sensory
level electroanalgesia)
Always choose treatment
first than choose suitable
waveform

International overlay

Options
There are 5 waveforms
approved for pain
management by the
FDA.
z Interferential Quad-Polar
z Premodulated Bi-polar
z Microcurrent
z TENS Symmetrical
and Asymmetrical
Biphasic

Electrotherapy Treatments for

Pain Modulation
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Sensory level electroanalgesia (AKA: high frequency

TENS, Conventional Tens)
Waveforms - IFC, Premod, HVPC, Biphasic
Motor level electroanalgesia (AKA: low frequency
TENS, acupuncture like TENS)
Waveforms - IFC, Premod, Biphasic
Brief Intense TENS (need a unit with on/off time)
Waveforms - Biphasic, Russian (AC)
* High Intensity Noxious Electrical Stimulation for pain
modulation

Sensory Level Electroanalgesia

AKA: High frequency TENS or Conventional TENS

Acute pain management

Phase Duration: 2-50 microseconds
Frequency: >80 pps
On/off time: none
Amplitude: Perceptible tingling, no motor
response should be elicited
Duration of Rx: 15-30 min

-Amplitude, frequency or duration modulations can be used to minimize accommodation-

Mech of action: segmental non-opiate, gate control theory

Sensory Level Electroanalgesia

Using the IFC or Premod
waveform
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Acute Pain Management

Gate Control
4 pad application (IFC), 2 pads (premod)
Carrier frequency: 5000 HZ (usually preprogramed)
Beat Frequency: 80-150 Hz, fast sweep
Intensity Level: Sufficient to produce a moderate

strong, sensory tingling effect, with no motor

response
Duration: 20-30 minutes
Interferential Stimulation: De Domenico Ph.D

Sensory Level Electroanalgesia

Clinical Application Notes
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Believed to relieve pain through the gate control theory of

pain modulation via hyperstimulation of A-beta nerves
Treatment of choice for acute conditions
Amplitude: increase to twitch and back off slightly
Literature reports little pain relief post Rx; pain relief
beyond Rx time may occur if pain-spasm cycle is
interrupted
Waveforms: Pulsed Current, *HVPC, IFC(AC), Premod
(AC)
Robinson AJ, Snyder-Mackler L. Clinical Electrophysiology. 2nd ed. Williams &
Wilkins.

Introduction to Motor Level

Electroanalgesia: Twitch Level
Stimulation
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Endorphins are released at a pulses rate

range of 1 to 15 pps (approx.) Twitch level
stimulation
Enkephalins are released at the higher pulse
rates of 80 pps and up. Twitch level
stimulation
Endorphin induced pain suppression lasts
longer than pain suppression induced by
enkephalins

Motor Level Electroanalgesia

AKA: Low frequency TENS, Acupuncture like Tens, opiate
induced electroanalgesia, twitch level stimulation

Phase Duration: 150 microseconds

Frequency: 2-4 pps ( 10 pps is acceptable)
On/off time: None
Amplitude: Strong visible muscle contraction
Duration of treatment: Literature suggests 3045 minutes
Robinson AJ, Snyder Mackler L. Clinical Electrophysiology

Motor Level Electroanalgesia

Using Premod or IFC waveform

Mode: 2 pad application(premod)

4 pad application (IFC)
Carrier frequency: 2500 5000 Hz (usually
pre-programed in machine (e.g. Chatt vectra =
5000Hz)

Beat Frequency:1 to 10 Hz or 2 Hz constant

On/off time: none
Intensity Level: Strong visible muscle
contraction
Duration: 30-45 minutes
Interferential Stimulation: De Domenico Ph.D

Motor Level Electroanalgesia

Clinical Application Notes
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Believed to reduce pain through the activation of

endogenous opiates
The literature reports greater carry over of pain
relief; up to several hours
Research suggests that stronger contractions
produce greater analgesia
Not a good choice for acute injuries
Waveforms: pulsed currents, IFC (AC), and
Premod (AC)

High Intensity Noxious

Electrical Stimulation for Pain
Modulation
Type of Stimulator: Alternating Current unit
Carrier Frequency: 2500 Hz
Frequency: 50 bursts / second
On / Off Time: 12 sec on / 8 seconds rest
Electrode Placement: Small electrodes (1x2cm)
directly over the site of pain
Amplitude: maximum tolerable
Treatment time: 10 minutes

High Intensity Noxious Cont..

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Excellent preliminary results in pilot studies and

in one published case report
Theoretical Construct of Case report
- Decreased force output (strength) can be
caused by mm inhibition secondary to
pain. not always a strength issue- speedy return of strength after just 2
ES treatments to painful patella tendon
No high quality research studies to date
Muller et al J Orthop Sports Phys Ther. 2000;30:138-142.

Brief Intense TENS

AKA: Hyperstimulation analgesia

Phase Duration: > 300 microseconds

Frequency: 100-150 pps
Amplitude: Noxious with visible and
palpable muscle contraction
On time: 10 -15 seconds
Off time: 4-7 seconds
Duration of Rx: 15-30 minutes

Brief Intense TENS:

Clinical Application Notes
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The high frequency (pps) and limited rest between

contractions is believed to induce electrical fatigue
of muscles in spasm
Since this is an aggressive treatment method, not
all patients are candidates
Not indicated for acute injuries
Good clinical results for reduction of muscle
spasm associated with LBP (opinion)
Duration of pain relief: < 30 min

Microcurrent
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Monophasic rectangular
wave with selectable or
alternating polarity
Stimulation at a subsensory
level (< 1mA)
Do you believe in something
you can not feel?

What are your experiences?

More studies are necessary

Clinical Applications
z Common

treatment guidelines:

Healing phase
z Ultra-low frequencies under 1 Hz (.3 Hz)
z Ultra-low amplitude 10-80 uA
Pain Settings
z High frequency 3 - 30 Hz
z Amplitude 150 - 600 uA
Patients not responding at 3-30 Hz range should proceed
to 300-990 Hz range
* Linda Manley M.Ed, ATC, PT - Microcurrent Universal Treatment
Techniques and Applications

Common Treatment guidelines

cont..
Treatment time:
z Probes
5-30 seconds per site
GSR mode helps locate areas of low impedance
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Electrodes
General soft tissue injuries 20-30 minutes
Nerve root and low back injuries 30-60 minutes

Polarity guidelines: positive for acute conditions

negative for chronic conditions

HVPC to Retard the formation of

Edema
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Fish, Mendel and associates published

extensively from 1990 through 1997 on
electrical stimulation and edema
HVPC waveform to a sensory level cathode at the

site of injury retards the formation of edema.

Stimulation when applied to acute inflammation does
not reduce it but retards the formation of edema.
Excellent addition to standard acute care of athletic
injuries; must begin prior to the formation of edema

HVPC: Prevention of Edema

z Mechanism
Reduce the leakage of
large protein
molecules and fluid
from the blood,
through the walls of
the small blood
vessels into the
interstitium.

Parameter Settings
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Waveform: Twin Peak High Volt Pulsed Current

Frequency: 120 pps
Polarity: Negative
Ramp: None
Amplitude: 10% below motor threshold
Time: 30 minutes 4 times per day
Electrode placement
Cathode (negative electrode) placed over the site of

injury. Should be smaller in size than the anode

(positive electrode)
Anode (positive) placed in a convenient site. Does not
need to be proximal as the effects are local effects.

Water Bath Technique

z Electrode

placement

Carbon rubber cathode (-) immersed in

room temperature water with

accompanying edematous limb
Anode (+) electrode placed proximally on
same limb or trunk

Summary of Key Points

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Treating the pain impairment can interrupt the

pain spasm cycle and allow rehab to progress
faster
Chose electrotherapy treatments based on stage of
tissue healing and desired physiologic response
Remember that the waveform is not the treatment
choose the treatment first than select a waveform
that has the necessary characteristics to deliver the
treatment. Often several correct options!

Summary of Key Points

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Utilize the continuum of electrotherapy treatments based

on stage of healing
Progress from sensory level to motor level analgesia
(opiates) when tissue is ready
Assess pain pre and post treatment to determine
effectiveness of electrotherapy the intervention
HVPC role in standard acute care of athletic injuries

Questions

Thank You
z Email

josephjag4@aol.com
z Office Number (603) 668-6660
x2119