Current Concepts and
Scope of Issues to cover . . .
Trends in Electrotherapy
Electrotherapy
Conference, Hong Kong.
Dec 2006
Professor Tim Watson
University of Hertfordshire
www.electrotherapy.org
Brief Historical Overview
o Brief historical overview
o Principles of all electrotherapy modalities
o Therapeutic windows and dose
dependency
o Range and classification of
electrotherapy modalities
o New and developing trends from the
evidence
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 Electrotherapy (ala US Army, 1920’s)

Bergonic chair used for ‘general electric treatment’

Principles of all
Electrotherapy Modalities

A General Model of
Electrotherapy

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 The Bioelectric Cell Approaches to Electrotherapy

o High Energy Intervention

Cell Cell membrane
Membrane thickness of o use sufficient energy to overcome the
Potential of 7 - 10 nm energy state of the cell and thereby
-70mV force it to change its mode of
behaviour
o Low Energy Intervention
o use a lower energy level, insufficient
to ‘force’ a change of mode, but
sufficient to bring about “up
regulation”
Cell Transport Mechanisms

e.g. e.g.
Ultrasound
TENS
Laser Therapy
Pulsed Shortwave Interferential
Therapy
NMES

Cellular Cellular Cellular Cellular

Tickling Thumping Tickling Thumping

Therapeutic Windows and

Dose Dependency

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 Example of an Amplitude and Frequency
Electrotherapeutic Windows Window

o Amplitude window
e.g. Litovitz 1990, Goldman 1996

o Frequency window
e.g. Cleary 1987, Goldman 1996

o Strong contention for Energy window

e.g. Watson 2000

o All are DYNAMIC

Window location movement with change

Using an ‘Acute Window’ to treat a
of tissue state Chronic problem

Effective chronic window

Acute

Chronic

Effective acute
treatment dose

Arndt-Shultz Law Representation

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 Examples of Dose Dependency
in Electrotherapy Research

Research Examples of Windows Sluka, K. A. et al. (2006). Increased release of

serotonin in the spinal cord during low, but not high,
o TENS - o US - FREQUENCY frequency transcutaneous electric nerve stimulation in
FREQUENCY o Fabrizio et al 1996 rats with joint inflammation.
o Hamza et al 1999 o Young & Dyson 1990 Arch Phys Med Rehabil 87(8): 1137-40.
o Han et al 1991 o US - AMPLITUDE
o Palmer & Martin 1999 o Kramer 1987 OBJECTIVE: To determine the release pattern of
o Walsh 1995 o Miller & Gies 1998 serotonin and noradrenaline in the spinal cord in
o Sluka et al 2006 response to transcutaneous electric nerve stimulation
o Reher et al 1997 (TENS) delivered at low or high frequency.
o TENS o Reher et al 2002 DESIGN: Prospective randomized allocation of 3
AMPLITUDE treatments.
o Chakour et al 2000 SETTING: Research laboratory. ANIMALS: Male
Sprague-Dawley rats (weight range, 250-350 g).

Sluka et al (2006) contd Sluka et al (2006) contd

o Knee joints of rats were inflamed with a mixture
of carrageenan and kaolin for 24 hours
o CSF samples were collected in 10-minute intervals
before, during, and after treatment with low-
frequency TENS (4 Hz), high-frequency TENS
(100 Hz), or sham TENS.
o TENS was applied to the inflamed knee joint for
20 minutes at sensory intensity and 100-mus
pulse duration.
o CSF samples were analyzed for serotonin and
noradrenaline
o RESULTS: Low-frequency TENS
significantly increased serotonin
concentrations during and immediately
after treatment. There was no change in
serotonin with high-frequency TENS, nor
was there a change in noradrenaline with
low- or high-frequency TENS.
o CONCLUSIONS: Low-frequency TENS
releases serotonin in the spinal cord to
produce antihyperalgesia by activation of
serotonin receptors.

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Research Examples of Windows
o TENS - o US - FREQUENCY
FREQUENCY o Fabrizio et al 1996
o Hamza et al 1999 o Young & Dyson 1990
o Han et al 1991 o US - AMPLITUDE . . . we have investigated the effect of the therapeutic range of
o Palmer & Martin 1999 o Kramer 1987 ultrasound on NO induction and prostaglandin E-2 (PGE(2))
o Walsh 1995 o Miller & Gies 1998 production in vitro. Two ultrasound machines were
o Sluka et al 2006 o Reher et al 1997 evaluated, "traditional" (1 MHz, pulsed 1:4, tested at four
o TENS o Reher et al 2002 intensities) and a "long-wave" (45 kHz, continuous, also
AMPLITUDE tested at four intensities) devices. . . . With the 45 kHz
o Chakour et al 2000 machine, a significant increase in NO was achieved at three
intensities, 5, 30, and 50 mW/cm(2). The 1 MHz machine
stimulated the synthesis of both NO and PGE(2), but was
significant at only one dose (0.1 W/cm(2(SAPA))). . . . . . . .

o LASER - o PSWD / RF
AMPLITUDE AMPLITUDE
o Pereira et al 2002 o Cleary 1987
o Karu 1987 o Frey 1974
o Shields et al 1993 o Hill et al 2002
o Tuner & Hode o Litovitz et al 1990
2002 o PSWD / RF
o Vinck et al 2003 FREQUENCY
o LASER - o Cleary 1987
MODULATION o ENERGY/TIME
o Martin et al 1991 o Hill et al 2002

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 Vinck, E. M. et al. (2003). Increased fibroblast proliferation
o LASER - o PSWD / RF induced by light emitting diode and low power laser
AMPLITUDE AMPLITUDE irradiation. Lasers Med Sci 18(2): 95-9.
o Pereira et al 2002 o Cleary 1987 BACKGROUND AND OBJECTIVE: As Light Emitting
Diode (LED) devices are commercially introduced as an
o Karu 1987 o Frey 1974 alternative for Low Level Laser (LLL) Therapy, the ability
o Shields et al 1993 o Hill et al 2002 of LED in influencing wound healing processes at cellular
level was examined.
o Tuner & Hode o Litovitz et al 1990
STUDY DESIGN/MATERIALS AND METHODS:
2002 o PSWD / RF Cultured fibroblasts were treated in a controlled,
o Vinck et al 2003 FREQUENCY randomized manner, during three consecutive days, either
with an infrared LLL or with a LED light source emitting
o LASER - o Cleary 1987
several wavelengths (950 nm, 660 nm and 570 nm) and
MODULATION o ENERGY/TIME respective power outputs. Treatment duration varied in
o Martin et al 1991 o Hill et al 2002 relation to varying surface energy densities (radiant
exposures).

RESULTS: Statistical analysis revealed a higher rate

o LASER - o PSWD / RF
of proliferation (p < 0.001) in all irradiated cultures in
AMPLITUDE AMPLITUDE
comparison with the controls. Green light yielded a
significantly higher number of cells, than red (p < o Pereira et al 2002 o Cleary 1987
0.001) and infrared LED light (p < 0.001) and than o Karu 1987 o Frey 1974
the cultures irradiated with the LLL (p < 0.001); o Shields et al 1993 o Hill et al 2002
the red probe provided a higher increase (p < 0.001) o Tuner & Hode o Litovitz et al 1990
than the infrared LED probe and than the LLL 2002 o PSWD / RF
source.
o Vinck et al 2003 FREQUENCY
CONCLUSION: LED and LLL irradiation resulted in o LASER - o Cleary 1987
an increased fibroblast proliferation in vitro. This study MODULATION o ENERGY/TIME
therefore postulates possible stimulatory effects on o Martin et al 1991 o Hill et al 2002
wound healing in vivo at the applied dosimetric
parameters.

Pereira, A. N. et al. (2002). Effect of low-power
laser irradiation on cell growth and procollagen
synthesis of cultured fibroblasts.
Lasers Surg Med 31(4): 263-7.
BACKGROUND AND OBJECTIVES:
This in vitro study focuses on the biostimulation of NIH-3T3
fibroblasts by a low-power Ga-As-pulsed laser
RESULTS: Irradiation of 3 and 4 J/cm(2) increased
the cell numbers about threefold to sixfold comparing
to control cultures. However, this effect was restricted
to a small range of energy densities since 5 J/cm(2)
had no effect on cell growth. The energy density of 3
J/cm(2) remarkably increased cell growth, with no
effect on procollagen synthesis, as demonstrated by
the immunoprecipitation analysis.

STUDY DESIGN/MATERIALS AND METHODS:

We have studied cell growth and procollagen synthesis of
cultured fibroblasts submitted to low-power laser irradiation
with energy densities varying from 3 to 5 J/cm(2) over a
period of 1-6 days.
CONCLUSIONS: Our results showed that a particular
laser irradiation stimulates fibroblast proliferation,
without impairing procollagen synthesis.

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 Sontag, W. (2000). Modulation of cytokine
o ELEC STIM production by interferential current in differentiated
o INTERFERENTIAL
AMPLITUDE HL-60 cells. Bioelectromagnetics 21(3): 238-44.
- FREQUENCY
o Noble et al 2000 o Turler et al 2000
The influence of interferential current (IFC) on the
o Sontag 2000 o Lundberg et al release of four cytokines was investigated. . . .
1989 Release of tumor necrosis factor alpha (TNFalpha)
o Lamb & Mani 1994
o ELEC STIM and interleukines 1beta, 6, and 8 (IL-1beta, IL-6,
o INTERFERENTIAL FREQUENCY and IL-8) was measured after exposure to IFC at
MODE o McDowell et al different modulation frequencies.
o Johnson & Wilson 1999
1997 o Takata & Ikata TNFalpha release was stimulated about twofold
2001 by 4 kHz sine waves alone.

The influences of exposure time (5-30 min) and

current density (2.5-2500 microA/cm(2)) were
tested.
A maximum field effect was found at an
exposure time of 15 min and a current density of
250 microA/cm(2).
With these exposure conditions, cells were
treated at different modulation frequencies and
reacted for TNFalpha, IL-1beta, and IL-8 release
in a complex manner.
Within the frequencies studied (0-125 Hz), we
found stimulation as well as depression of the
release.

Saunders, L. (2003). "Laser versus ultrasound in the

treatment of supraspinatus tendinosis." Physiotherapy
89(6): 365-373.

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 Electrical Thermal Non Thermal
Stimulation Modalities Modalities

Range and Categories of TENS

Shortwave
Diathermy
Ultrasound

Electrotherapy Modalities Interferential

Therapy
Microwave
Diathermy
Therapeutic
Laser

Chronic
Pulsed
Neuromuscular Infra Red
Stimulation Shortwave

Diadynamic Wax and Hot

Currents Packs The Scope of
Reebox &
Electrotherapy
H Wave, Russian [Ultrasound]
Stimulation

Some Issues . . . .

o Ultrasound for Fracture Healing

Trends, New and
Developing Electrotherapies
– from the Evidence
o Microcurrent therapy for enhanced
repair
o Magnetic therapies
o Various novel forms of electrical
stimulation

US and Fracture Healing RCT’s Human Fresh Fractures

o Numerous animal studies and also o Heckman et al (1994)

o Tibial #
several quality human RCT’s
o 38% reduction time to heal c/f mock
o Kristiansen et al (1997)
o Ironic that considered a o Distal radius #
contraindication by many therapists o 38% reduction time to heal c/f mock

but actually has better evidence o Mayr et al (2000)

o Scaphoid #
than many other US applications o 30% reduction time to heal c/f mock

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 Analysis . . . .
o Busse et al (2002) & Warden (2003)
o Meta analysis of fresh fracture (quality)
studies
o Pooled results of 158 #’s
o Weighted average effect gives mean
difference of 64 days in healing times
between active & inactive US treatments
o Treatment advantage averages 1.6 in
favour of US group
Jensen (1998)
Low Intensity Ultrasound for
Stress Fractures
o Low intensity ultrasound for stress
fracture treatment (as opposed to
diagnosis)
o 96% healing rate claimed when
compared with placebo intervention

Delayed and non union . . .

o Mayr et al (2000)
o Nolte et al 2001
o Takikawa et al (2001)

o Significant results in human RCT

and controlled trials

US Fracture Doses
?Normal Physiotherapy Machines?
o LIPUS (low intensity pulsed US)
o Potential to be realised with ‘normal’
o Frequency usually 1.5MHz physiotherapy devices in future models
o ISATA of 0.03 W cm-2 o ?can us PTY machines set at 0.1W cm-2
o Duty Cycle 20% but BNR problems
o Warden et al 1999 (Phys Ther Rev
o Special devices 4;117-126)
o Exogen 2000™
o Warden 2003 (Sports Med 33(2);95-
o SAFHS™ (Sonic Accelerated Fracture 107)
Healing System)
o Warden et al 2006 (Phys Ther 86(8):
o 20 min 1xdaily – self administered by 1118-27)
patient

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 Warden, S. J. et al. (2006). Ultrasound
produced by a conventional therapeutic
ultrasound unit accelerates fracture repair.
Phys Ther 86(8): 1118-27.
BACKGROUND AND PURPOSE: The aim of this study was to
investigate the effect on fracture repair of ultrasound produced
by a conventional therapeutic ultrasound unit as used by physical
therapists.
SUBJECTS AND METHODS: Bilateral midshaft femur fractures
were created in 30 adult male Long-Evans rats. Ultrasound
therapy was commenced on the first day after fracture and
introduced 5 days a week for 20 minutes a day. Each animal was
treated unilaterally with active ultrasound and contralaterally
with inactive ultrasound. Active ultrasound involved a 2-
millisecond burst of 1.0-MHz sine waves repeating at 100 Hz.
The spatially averaged, temporally averaged intensity was set at
0.1 W/cm2. Animals were killed at 25 and 40 days after
fracture induction, and the fractures were assessed for bone
mass and strength.
Microcurrent Therapy for
Enhanced Tissue and
Wound Repair
Posifect : an example of
a microcurrent wound
care device
Warden et al 2006 (contd)
RESULTS: There were no differences between fractures
treated with active ultrasound and fractures treated with
inactive ultrasound at 25 days. However, at 40 days, active
ultrasound-treated fractures had 16.9% greater bone mineral
content at the fracture site than inactive ultrasound-treated
fractures. This change resulted in a 25.8% increase in bone
size, as opposed to an increase in bone density, and
contributed to active ultrasound-treated fractures having
81.3% greater mechanical strength than inactive ultrasound-
treated fractures.
DISCUSSION AND CONCLUSION: These data indicate that
ultrasound produced by a conventional therapeutic ultrasound
unit as traditionally used by physical therapists may be used to
facilitate fracture repair. However, careful interpretation of
this controlled laboratory study is warranted until its findings
are confirmed by clinical trials.
Existing (established) therapy
o Many publications in the fieldof
wound repair using a variety of
‘microcurrent’ therapies
o Uses principle of ENDOGENOUS
CURRENT ENHANCEMENT
o Numerous reviews including Watson
2002, 2006, Kloth 2005
Bone and Fractures
o Also a variety of strong research
papers that identify the clinically
significant value of applying
‘microcurrents’ to fractures to
stimulate repair / healing
o Also very useful for delayed / non
union
o E.g. Kesani et al. (2006),
Rodriguez-Merchan (2004)
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Potential for Soft Tissues?
o There is a strong physiological
rationale for the employment of
microcurrent type therapies in the
case of soft tissue injury
o Watson 2006, Lambert 2002
o No substantive work, but we are
just embarking on a 4 year
research programme
Magnetic Therapies
Magnetic Therapy possibilities
o There is a significant amount of
research ongoing with regards the
potential benefits of magnetic
therapy as an additional tool in the
workbox
o Some (limited) good quality work
o Many machines already on the
market
Microcurrents and Soft Tissue
Injury
o Will include something of the
rationale and background in the
soft tissue repair session
Magnetic therapies examples :
o White, R. et al. (2006). Magnet therapy:
opening the debate. J Wound Care 15(5): 208.
o Swanson, J. and L. Kheifets (2006). Biophysical
mechanisms: a component in the weight of
evidence for health effects of power-frequency
electric and magnetic fields. Radiat Res 165(4):
470-8.
o Okano, H. et al. (2006). Effects of a
moderate-intensity static magnetic field on
VEGF-A stimulated endothelial capillary tubule
formation in vitro. Bioelectromagnetics 27(8):
628-640.
o Owegi, R. and M. T. Johnson (2006). Localized
pulsed magnetic fields for tendonitis therapy.
Biomed Sci Instrum 42: 428-33.
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 Dose issues :
o There are over 2000 references in
my database relating to magnetic
therapies, physiology and biophysics
o BUT there is currently insufficient
(quality) evidence to make a strong
and substantiated move into clinical
practice
o Main issues relate to effective and
ineffective dose parameters
Conclusions II
o There are 2 fundamental
approaches to therapy : Thumping
and Tickling(!)
o Therapeutic Windows and Dose
dependency are KEY issues
o More work to be done and many
evidence gaps to fill
BUT . . . .
o Electrotherapy remains (in my
opinion) an ADJUNCT to treatment
rather than a replacement for
other therapies
o Used appropriately, it can be VERY
effective
o Used inappropriately, it remains a
complete waste of time and effort
Conclusions
o Electrotherapy has an historical
track record in physiotherapy
o The machines, delivery systems and
evidence continue to change
o BUT the principles remain the same
o ENERGY – PHYSIOLOGY -
THERAPY
Conclusions III
o New trends are emerging with
improved outcomes and further
possibilities
o Trend for lower doses once the
windows are identified
o ‘New’ modalities and new uses for
established ones
o Plenty of exciting possibilities
Thank You
www.electrotherapy.org
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