Europace (2009) 11, 850–859 REVIEW

doi:10.1093/europace/eup102

Physiotherapy and cardiac rhythm devices: a

review of the current scope of practice
Geneviève C. Digby 1, Marguerite E. Daubney 2, Jim Baggs2, Debra Campbell1,
Christopher S. Simpson 1, Damian P. Redfearn 1, F. James Brennan 1,

Downloaded from https://academic.oup.com/europace/article/11/7/850/498953 by guest on 29 November 2022

Hoshiar Abdollah 1, and Adrian Baranchuk 1*
1
Cardiac Electrophysiology and Pacing, Arrhythmia Service, Kingston General Hospital K7L 2V7, Queen’s University, Kingston, Ontario, Canada; and 2Blaser’s Physiotherapy and
Acupuncture Clinic, Kingston, Ontario, Canada

Received 15 December 2008; accepted after revision 4 April 2009; online publish-ahead-of-print 2 May 2009

Aims Several case reports have demonstrated negative interactions between various physiotherapy modalities and cardiac
rhythm devices (CRD). Fear of these potential interactions may lead to suboptimal utilization of physiotherapy treat-
ments in CRD patients. No prior review of available guidelines, or management strategies, on the interaction between
physiotherapy modalities and CRD patients has been reported. To review existing guidelines regarding the use of
physiotherapy modalities in patients with pacemakers and/or implantable cardioverter-defibrillators (ICDs). To retro-
spectively analyse CRD patient encounters at a local physiotherapy facility during a period of 2 years.
.....................................................................................................................................................................................
Methods A review of the literature regarding the potential interactions between physiotherapy modalities and CRDs was
and results performed. Next, a 2 year retrospective analysis of patient encounters at a physiotherapy facility was conducted.
In addition, seven international physiotherapy societies and four CRD manufacturers were surveyed with respect
to recommendations regarding physiotherapy treatments in device patients. The local physiotherapy facility
treated 25 patients with CRD (22 pacemaker and 3 ICD patients) for a total of 230 visits (9.2 visits/patient). Five
patients received transcutaneous electrical nerve stimulation (TENS) and all 25 were administered additional
treatment in the form of ultrasound (15), acupuncture (19), Laser (7), traction/manual therapy (12), exercise (8),
education (18), taping (5), and/or moist heat (5). No complications occurred. Meanwhile, international societies
and device manufacturers offered few specific or consistent recommendations.
.....................................................................................................................................................................................
Conclusion There are no specific international policies regarding the administration of physiotherapy modalities in CRD patients
and, thus, there are no specific guidelines to be implemented at the local level. Review of the literature and of rec-
ommendations from CRD manufacturers suggests that TENS, Diathermy, and Interferential Electrical Current
Therapy are best avoided in patients with CRDs. However, there is no consensus and it may be possible to safely
deliver these modalities in a proper setting with device and patient monitoring. Although further research is required
in this regard, active collaboration between physiotherapists and CRD clinic physicians should allow for the safe
application of most physiotherapy modalities.

these devices have been shown to prolong survival in well-defined

Introduction
The interactions between cardiac rhythm devices (CRD) and phys-
ical therapy procedures using sources of possible electromagnetic
interference (EMI) have been reported for decades.1 – 3 Even so,
the extent to which physical therapy procedures are safe in
patients with CRD, namely permanent pacemakers and implanta-
ble cardioverter-defibrillators (ICDs), is still unclear. Given that
patient populations4 – 7 and that implant rates are increasing, it is
anticipated that an increasing number of CRD patients will be pre-
senting to physiotherapy centres requiring treatment with phy-
siotherapy modalities.
There is a concern that patients with CRD may be less likely to
receive optimal care as a result of the preconception that some
physical therapy modalities are potentially harmful to this patient

* Corresponding author. Tel: þ1 613 549 6666, Fax: þ1 613 548 1387, Email: barancha@kgh.kari.net
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2009. For permissions please email: journals.permissions@oxfordjournals.org.
Physiotherapy and cardiac rhythm devices
population. Given the paucity of good data on safety, it is under-
standable that physiotherapists tend to adopt a conservative
approach to decision making in this patient population,8 and this
often leads to a decision to forego treatment in a patient who
would otherwise be expected to derive benefit. In fact, it is not
uncommon to see a patient with a pacemaker or ICD who may
have benefited from electrical pain treatment or the use of
another physiotherapy modality—but who has been denied this
treatment on the basis of the fact that they have a CRD.9
In this paper, we review the current standards that exist at the
local and international levels regarding the use of various physical
therapy modalities in patients with pacemakers or ICDs. In order
to assess safety issues and to develop recommendations, it is
important to understand the indications for and the technical con-
siderations of each modality, as well as to review the current evi-
dence regarding potential interactions of the various treatment
modalities with pacemakers or ICDs. Thus, we begin with a brief
review of the literature regarding these potential interactions.
Then, at the local level, we review the policy of care of a phy-
siotherapy centre in a city of 150 000 inhabitants (Kingston,
Ontario, Canada). Finally, at the international level, we investigate
the standards that are used throughout the world, including the
recommendations from cardiac device manufacturers and inter-
national physiotherapy societies.
Methods
Current standard of practice for patients with
cardiac rhythm devices at a local
physiotherapy facility
In order to assess the current standard of practice in a local phy-
siotherapy centre, we conducted a retrospective analysis of all
patient encounters that occurred within a 2 years period. The
number of individual patients seen by this centre as well as the total
number of patient encounters was recorded. A specific analysis was
conducted on patients who presented with a CRD. All of these
patients were analysed by retrospective chart review in order to deter-
mine the nature of the treatment recommended by the clinic staff and
the clinical outcomes.
Recommendations from international
physiotherapy societies
To assess the existing international policies and recommendations
regarding the use of physiotherapy modalities in CRD patients, we
contacted the national physiotherapy societies or associations govern-
ing physiotherapists in the English-speaking world, namely: the
American Physical Therapy Association (APTA), the Australian Phy-
siotherapy Association (APA), the Canadian Physiotherapy Association
(CPA), the Chartered Society of Physiotherapists (CSP), and the Irish
Society of Chartered Physiotherapists (ISCP). We also contacted the
Ontario Physiotherapy Association (OPA) as well as the International
Society of Education in Physiotherapy (ISEP) to obtain more local and
international guidelines. Societies were initially contacted by email
using addresses acquired from their websites. An inquiry was posed
as to whether the society had implemented any policy or regulation
regarding the administration of various physiotherapy modalities in
patients with pacemakers or ICDs. If a response had not been
851
obtained, a contact by telephone was attempted until all societies
had been contacted.
Recommendations from cardiac rhythm
device manufacturers
Cardiac rhythm device manufacturers were contacted to obtain their
current international recommendations regarding the administration
of various physical therapy modalities in patients implanted with
their devices. The Canadian representative of each company was con-
tacted by email (Medtronic, Boston Scientific, St Jude Medical and
Sorin Group– ELA). Electronic copies of the manufacturer-specific rec-
ommendations were obtained from each company.
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Commonly used physiotherapy modalities
and documented interactions with cardiac
rhythm devices
The following is a summary of the more frequently used physical
therapy modalities and documented interactions between physical
therapy modalities and CRD.
Acupuncture
Acupuncture involves the insertion of needles into the skin at specific
points in order to relieve pain. This therapeutic modality is generally
considered to have a low risk of interfering with pacemakers or
ICDs because of the lack of electrical current being used.10
However, case reports suggest possible adverse reactions to acupunc-
ture in patients with CRD. Apaloo11 reported a case of a patient with a
pacemaker experiencing an episode of syncope during acupuncture
treatment. Notably, this patient also experienced several episodes of
syncope during electro-acupuncture treatment, which involves electri-
cal stimulation of the acupuncture needles by various frequencies and
voltages to provide a longer-lasting pain blocking effect. The author did
not report abnormal findings on pacemaker interrogation.
Acupuncture-related syncope may have a different aetiological origin
than pacemaker interference, given several reports of syncope during
acupuncture in patients with no cardiac devices.12
Overall, it seems as though acupuncture may be a relatively benign
treatment in CRD patients, but the extent to which adverse effects are
likely to occur, especially in the case of electro-acupuncture, needs to
be further investigated.
Diathermy
Diathermy refers to the deep heating of tissues by either ultrasound
(US) or electrical means in order to relieve pain. Short-wave diathermy
(SWD) specifically refers to the therapeutic application of radiofre-
quency electromagnetic radiation in order to achieve deep tissue
heating.8 Treatment may be applied as either a continuous beam of
energy (CSWD) or pulses of energy (PSWD). Because of the nature
of this treatment, it is potentially dangerous to use it in patients with
CRD. The generated heat can cause burning to surrounding tissues
and damage the circuitry of the pacemaker, but also, the electromag-
netic fields generated may directly interfere with the performance of
the device.8
There is very little evidence-based literature that addresses the issue
of potential interference between SWD and CRD. In fact, as pointed
out by Shields et al.,8 electrotherapy textbooks provide only broad
contraindications to SWD and the literature available is not sufficiently
comprehensive to substantiate all the suggested contraindications to
electrotherapeutic agents. The few studies that exist are largely out-
dated, and may no longer be applicable to modern CRD. One
review13 noted interference in pacemakers due to CSWD application
852
and found that patients wearing demand pacemakers were more vul-
nerable to interference than asynchronous ones. Valtonen et al.14
found that CSWD caused pacemaker output to decrease and pulse
rate to increase. These induced changes were dependent on applied
power, electrode-pacemaker distance, and orientation of the pace-
maker and leads relative to the electrical field. Although the effects
of SWD on pacemakers have been investigated in the laboratory,
very little evidence exists regarding these interactions in the human
body. Thus, in order to err on the side of caution, it has generally
been accepted that SWD of any form should be contraindicated in
patients with both dependent and non-dependent pacemakers.8 In
our service, dependency is defined as an absence of intrinsic signals
when the pacemaker is programmed at 40 b.p.m. Another study15
found no disruption in eight pacemaker patients being treated with
SWD, a finding that was believed to reflect modern developments in
pacemaker shielding. It has also been suggested that treatment of
extremities in patients with pacemakers is permissible given the remo-
teness of the treatment site from the device.16 The review from
Shields et al.8 compiles the contraindications as advocated by text-
books, published articles, and device manufacturers’ literature into a
list to be used by physiotherapists in clinical practice. On the basis
of the evidence listed above, they included pacemakers among their
list of contraindicated devices. Implantable cardioverter-defibrillators
are not specifically mentioned, but as the review contraindicates
implanted metal devices as well, it is likely that ICDs would fall into
the contraindicated category along with their pacing counterparts. In
fact, even the US Food and Drug Association (FDA) has broadcasted
a warning against the use of diathermy in a patient with any implanted
metallic lead in the body, including cardiac pacemakers and implantable
defibrillators, after two patients with implanted devices (neurostimula-
tors) died as a result of diathermy treatment.17 Even so, Shields et al.8
point out that this is a complex and poorly evidenced area, and while
limited (largely anecdotal) evidence is available, some of the infor-
mation presented is deductive and therefore contraindications are
typically based on consensus rather than evidence.
Interferential electrical current therapy
Interferential current therapy is a treatment to aid the relief of pain and
promotion of soft-tissue healing. It is similar to a transcutaneous elec-
trical nerve stimulation (TENS) unit, but provides deeper penetration
and less patient discomfort. Case reports specifically relating to this
form of treatment are not available, but deductive reasoning has led
one device manufacturer (Medtronic) to advise that the electrical
current applied to the body in this form of treatment may affect
implanted devices.10
Light amplification stimulated emission of radiation
Light amplification stimulated emission of radiation (Laser) therapy is
the application of red and near infra-red light to improve tissue
healing and relieve pain. It has become a popular modality to treat
musculoskeletal and skin disorders with an athermic effect and has
been reported to have a substantial therapeutic role in rheumatoid
arthritis, post-traumatic joint disorders and myofascial pain.18
However, little has been reported with regards to the safety of
Laser therapy in patients with CRD. A review by Volkman et al.19
suggests that Laser application poses no risks to the pacemaker
patient and that its relative safety is comparable to that of US, direct
currents, thermotherapy, and phototherapy.
Manual therapy/traction
Manual therapy and traction involve the mobilization of the soft tissues
and joints of the body in order to relieve pain and promote healing.
G.C. Digby et al.
No specific recommendations exist surrounding the safety of various
massage therapy and traction procedures in patients with CRD. This
is likely a result of the lack of electrical current being used and the
lack of deep tissue heating involved in this form of physiotherapy—a
putative mechanism for device interference has not been postulated.
Transcutaneous electrical nerve stimulation
Transcutaneous electrical nerve stimulation is a commonly used treat-
ment for the relief of acute and chronic musculoskeletal pain. It
involves placing electrodes on the skin, through which TENS is
applied at varying frequencies, intensities, and pulse durations of stimu-
lation in order to maximize pain relief.20 Pinski and Trohman21
reviewed the evidence indicating adverse interactions between TENS
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and CRD. They concluded that TENS could be used safely in patients
with modern implanted bipolar pacemakers and in patients with uni-
polar pacemakers if sensitivity were reduced. Eriksson et al.1 reported
inhibition by TENS in four patients with non-programmable unipolar
pacemakers, whereas other studies found that inhibition by a TENS
machine could be eliminated by making the pacing device less sensi-
tive.22 However, the risk associated with reducing the sensitivity of
the device is that if the native signals are smaller than the EMI
signals, this may predispose to undersensing and competition with
the intrinsic rhythm. Meanwhile, other authors have been unable to
confirm the observation that TENS may lead to interference of
pacing devices; they found no interference, inhibition, or automatic
reprogramming.2
Despite several cases demonstrating EMI between TENS and pace-
makers, fewer cases have been reported on the interactions between
TENS and ICDs. One report describes a patient in whom a TENS unit
created an electrical artefact that was interpreted by a transvenous
ICD as ventricular fibrillation, leading to spurious shock treatment.23
A safety study24 showed that neuromuscular electrical stimulation
could cause EMI leading to interference in atrial and ventricular
sensing or intermittent ventricular undersensing due to post-sense
blanking. Although EMI did not trigger an inappropriate ICD therapy
in this study, interference was seen when stimulation was applied
close to the ICD and during leg muscle therapy, regardless of interelec-
trode spacing or sensing mode. The authors suggested that not only
could EMI affect ventricular pacemaker or ICD tachycardia detection
algorithms, but could also trigger atrial mode switch episodes or inap-
propriate atrial therapies. Siu et al.25 published another case in which
TENS therapy applied to the mid-back resulted in two consecutive
shocks to a patient with an ICD. The shocks were attributed to EMI
simulating a series of low-voltage-ventricular signals that were inter-
preted as ventricular fibrillation, resulting in shock delivery. Several
other cases have confirmed interference of ICD function with TENS
treatment, including interference with pacemaker function in patients
with biventricular ICDs,26 as well as several cases of inappropriate
shocks with exposure to TENS.27
More recently, a study on EMI in 30 patients with ICDs was con-
ducted.9 In this study, it was found that TENS produced EMI triggering
inappropriate detection of VT/VF. Interference was found more fre-
quently in systems with integrated vs. dedicated bipolar leads. Interfer-
ence was also more likely to occur when TENS treatment occurred at
the mammilla than at the hip, and at a frequency of 80 Hz as opposed
to 2 Hz. Because of the potentially serious consequences of interfer-
ence, they concluded that TENS should not be recommended for
patients with ICDs.
Transcutaneous electrical nerve stimulation is perhaps the best-
studied physiotherapy modality in terms of its interactions with
CRD. Nonetheless, the clinical evidence is limited and, consequently,
the medical community acts conservatively by contraindicating the
Physiotherapy and cardiac rhythm devices
use of this device in CRD patients. Overall, the risk of TENS interfer-
ence seems to be lower when electrode placement is further away
from the device and when a lower frequency is used. Perhaps under
such situations of controlled distance and frequency, and by sub-
selecting populations with lower risk—such as bipolar systems in non-
dependent patients—TENS may be safe enough to be used. Finally,
one could perhaps envision the delivery of TENS in a monitored
setting, with ICD therapies temporarily turned off, to facilitate the
treatment required.
Ultrasound
Ultrasound therapy uses high-energy sound waves to help relieve mus-
culoskeletal pain. Although no evidence-based literature specifically
refers to the safety of US therapy in patients with CRD, the manufac-
turers of these devices report few EMI concerns in this regard. Med-
tronic suggests maintaining a distance of 15 cm (5.9 in.) between the
US transducer head and the implanted device to minimize mechanical
damage to internal circuitry of pacemaker or ICD.10
Results
Current standard of practice regarding
patients with cardiac rhythm devices
at a local physiotherapy facility
The retrospective data collected from the local physiotherapy facil-
ity analysed all patient encounters that occurred within the 2 years
period from 1 June 2006 to 1 June 2008. During this time period,
2780 patients presented to this physiotherapy centre a total of
31 918 times, with an average number of patient visits of 11.5
(range 1–27). Of these patients, 25 had an implanted CRD and
accounted for 230 of the visits to this clinic, (average of 9.2 visits
per patient). The patients with implanted devices included
22 patients with pacemakers and 3 patients with ICD (single
chamber 13 patients, dual chamber 10 patients, biventricular
2 patients).
Of the 25 device patients, five presented on two separate
occasions for treatment of different clinical problems. Thus,
there were a total of 30 occasions in which a CRD patient pre-
sented to the physiotherapy clinic for treatment. None of the
patients that presented to the physiotherapy clinic with a CRD
were denied care. In five cases (occurring in five different patients),
TENS was administered despite the presence of a CRD. Alterna-
tive forms of treatment commonly believed to be associated
with a lower risk of interference with CRD were administered
to the remaining 25 cases, as well as to the five patients receiving
TENS therapy. This care occurred in the form of US (15 cases),
acupuncture (19 cases), Laser (7 cases), traction or manual
therapy (12 cases), exercise (8 cases), education (18 cases),
taping (5 cases), or moist heat (5 cases). The body parts being
treated in all the CRD patients included lower back (18), neck
(8), shoulder (4), hip (4), arm/hand (2), leg/foot (5), or other (2).
With regards to the five patients who received TENS therapy,
the body parts being treatment included lower back (1), neck
(1), arm/hand (1), and leg/foot (2). In one of the 30 CRD patient
cases, the Arrhythmia Service at the local tertiary care centre
was consulted regarding the care of the patient. The consult
853
occurred to discuss the relative safety of administering TENS to
the patient which was later applied with no adverse outcome.
Recommendations from international
physiotherapy societies
The responses acquired from surveying the designated inter-
national physiotherapy societies and associations are summarized
in Table 1. The majority of these societies had no specific rec-
ommendations regarding the use of various physiotherapy modal-
ities in patients with CRD. The APA as well as the International
Society of Educators in Physiotherapy, based out of Australia,
both referred us to the Guidelines for the Clinical Use of Electro-
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physical Agents as developed by Robertson et al.28 in 2001 for the
APA. This document states that the provided guidelines err on the
conservative side and that some historically accepted contraindica-
tions and precautions are repeated due to the absence of adequate
research findings to exclude them. These guidelines suggest that
deep heating in the form of SWD should be contraindicated in
patients with inbuilt stimulators (such as pacemakers) within 3 m
of the device, whereas microwave diathermy and US therapy
(with or without heat) should be contraindicated directly over
the pulse generator device. The use of electrical stimulators (e.g.
TENS) with transthoracic application or long duration direct
current is also contraindicated. No precautions are listed for
Laser therapy or for superficial heating in the form of infra-red
or moist heat.
Recommendations from cardiac rhythm
device manufacturers
Electronic copies of recommendations regarding the use of phys-
ical therapy modalities in patients with CRD were obtained from
four CRD manufacturers. These data are summarized in Table 2.
The following physical therapy modalities are reported to be
associated with a risk of affecting implanted pacemaker or ICD
function and are advised against being administered to patients
with CRD by the device manufacturers listed in parentheses: Inter-
ferential Electrical Current Therapy (Medtronic),10 Microcurrent
Electrical Therapy (Medtronic),10 TENS (Medtronic, Guidant–
Boston Scientific, St Jude Medical)10 (Hospital EMI and the
Pacemaker/Implantable Cardioverter Defibrillator (ICD) Patient,
personal communication; Diathermy Warning from User’s Manual
& TENS Therapy and ICD, personal communication), Diathermy
(Guidant –Boston Scientific, St Jude Medical, Sorin Group–ELA)
(Hospital EMI and the Pacemaker/Implantable Cardioverter Defi-
brillator (ICD) Patient, personal communication; Diathermy
Warning from User’s Manual & TENS Therapy and ICD, personal
communication; Sorin Group, personal communication), Ultra-
sound (Sorin Group–ELA) (Sorin Group, personal communi-
cation). The following physical therapy modalities are reported
to have a low risk of interfering with CRD by the manufacturers
listed in parentheses: Acupuncture (Medtronic),10 Magnetic
Therapy (Medtronic),10 Pulse Radiation Therapy (Medtronic),10
Ultrasound (Medtronic, Guidant –Boston Scientific)10 (Hospital
EMI and the Pacemaker/Implantable Cardioverter Defibrillator
(ICD) Patient, personal communication), as well as TENS (Sorin
Group–ELA) (Sorin Group, personal communication).
854 G.C. Digby et al.

Table 1 Summary of international physiotherapy societies recommendations

Society Recommendation
...............................................................................................................................................................................
APTA (American Physical Therapy Association)a No comment
APA (Australian Physiotherapy Association) Refer to Robertson et al.28
† Deep heating: SWD C/I within 3 m of inbuilt pulse generator (e.g. pacemaker); MW and US C/I
over pulse generator
† Superficial heating or cold: no C/I
† EStims (electrical stimulation e.g. TENS)—C/I over stimulator
† US (no/low heat)—C/I over pulse generator
† UV/Laser—no C/I
CPA (Canadian Physiotherapy Association)b

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No specific recommendations are implemented. A document is in preparation at the time of
writing.
OPA (Ontario Physiotherapy Association)c No specific recommendations are implemented.
International Society of Educators in Physiotherapy Refer to Robertson et al.28
(Australia)
Chartered Society of Physiotherapists (UK)d No comment
Irish Society of Chartered Physiotherapistse No comment

C/I, contraindicated; SWD, short-wave diathermy; MW, microwave diathermy; US, ultrasound.
a
800/999-APTA (2782) (personal communication, 3 July 2008).
b
information@physiotherapy.ca (personal communication, 30 June 2008).
c
physiomail@opa.on.ca (personal communication, 30 June 2008).
d
enquiries@csp.org.uk (personal communication 02 July 2008, 24 July 2008), sarah.bazin@heartofengland.nhs.uk (personal communication, 29 July 2008), þ44 (0)20 7306 6666
(personal communication, 29 July 2008).
e
k.cradock@st-vincents.ie (personal communications, 2 July 2008, 9 July 2008, and 24 July 2008).

Future directions: communication
between physiotherapists and cardiac
rhythm device clinics
Clinical guidelines and recommendations regarding the use of
various physical therapy treatment modalities in patients with
CRD are often lacking, inconsistent, and/or inexplicit. Certainly,
device patients being considered to receive physical therapy treat-
ment involving various sources of EMI require careful consider-
ation to ensure their safety. To avoid unnecessary complications
to the CRD patient, many factors need to be considered including
the patient’s dependence on the device, the type of device, the
device manufacturer, as well as the treatment method and location.
As previously recommended, when in doubt regarding diagnostic
or therapeutic procedures that may result in cardiac device inter-
ference, a consultation ought to be performed to the device
centre. A collaborative consultation process would ensure an indi-
vidualized approach to treatment involving physiotherapists,
arrhythmia physicians, device manufacturers, and CRD clinic
(CRDC) staff. This individualized approach to treatment would
expedite the transfer of pertinent patient information between
the Physiotherapy Clinic and the Cardiac Rhythm Device team.
A collaborative and consultative process would identify patients
who might truly be at risk of negative consequences with a particu-
lar therapy and would ensure proper follow-up for these patients.
Such a collaborative consultative process is being developed for
CRD patients at our centre based on our previous successful experi-
ence with device patients receiving radiation therapy.29 It has culmi-
nated in the creation of two forms. The first form (Appendix 1) is to
be completed and faxed to the CRDC by the Physiotherapist who is
consulting the Arrhythmia Service. Once the Pre-Physiotherapy
Screening Pacemaker/Implantable Cardioverter Defibrillator (ICD)
Assessment Request Form is received in the CRDC, the information
will be reviewed by the arrhythmia physician. The second form
(Appendix 2) will be completed by the arrhythmia physician outlin-
ing their recommendations. The device manufacturer will be con-
tacted at the discretion of the arrhythmia physician. Once the
Arrhythmia Service Response to Physiotherapy Clinic Form is com-
pleted, it is faxed back to the Physiotherapy Clinic.
Given the logistical difficulties that would be involved in
attempting to arrange for the arrhythmia service and phy-
siotherapy clinic to meet to assess these patients together, we
suggest using these forms as a mean of providing an exchange
of pertinent patient information between the two treatment
facilities. This collaborative process ensures that patients are
individually assessed, provided optimal care and are adequately
followed.
Discussion and conclusion
Despite years of research, there is no comprehensive policy that
addresses the extent to which physical therapy modalities are
safe to be used in patients with CRD. The majority of international
societies offer no specific recommendations regarding the use of
safety of physical therapy modalities in patients with CRD,
whereas the device manufacturers themselves are not always con-
sistent with regards to their recommendations. In terms of the
local experience, it was found that there was no comprehensive
policy that allowed physiotherapists to determine whether a
Physiotherapy and cardiac rhythm devices 855

Table 2 Cardiac rhythm device manufacturers’ recommendations for use of physical therapy modalities in cardiac
rhythm device patients

Physical therapy modality Recommendations

...............................................................................................................................................................................
Medtronic10
Acupuncture—no electrical stimulus Low risk of affecting pacemaker or ICD
Interferential Electrical Current Therapy Potential pacemaker reversion or magnet rate
Potential ICD shock
Recommend magnet application for ICD and pacemakers
Magnetic Therapy Low risk when following safety precautions
Potential pacemaker reversion or magnet rate

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Potential disable of ICD detection circuit
Maintain a 6 in. (15 cm) distance between all therapy magnets and an implanted device
MET (Microcurrent Electrical Therapy) Potential pacemaker reversion or magnet rate
Alpha-Stim 100w
Potential pacemaker inhibition
Potential ICD shock
Pulse Radiation Therapy Low risk when following safety precautions
Potential pacemaker reversion or magnet rate
Potential pacemaker inhibition
Potential ICD shock
Magnet application recommended for pacemaker and ICD. Nerve ablation can damage pacemaker and ICD
circuitry, if it is administered within 6 in. (15 cm) of the device. If the ablation is farther than 6 in. (15 cm),
there is the potential for pacemaker reversion or ICD shock.
TENS Unit (Transcutaneous Electrical Potential pacemaker reversion or magnet rate
Nerve Stimulation)
Potential pacemaker inhibition
Potential ICD shock
There is a lower risk of the pacemaker or ICD detecting TENS when used on extremities
Ultrasound diagnostics/therapeutics Low risk when following safety precautions
Maintain a 6 in. (15 cm) distance between the transducer head and the implanted device
Guidant–Boston Scientific28
Diathermy Direct current interference
Possible inhibition of pacing or asynchronous pacing
Possible device reset
Risk of inappropriate shock
Possible device damage due to heating effects
Recommendations: temporarily deactivate ICD, no direct contact, monitor patient and watch for
interactions, confirm normal device operation and programmed parameters
TENS (Trancutaneous electrical nerve Direct current interference
stimulation)
Possible inhibition of pacing or asynchronous pacing
Risk of inappropriate shock
Generally contraindicated for patients
Recommendations: place TENS electrodes as close together as possible, place TENS electrodes as far from
device/lead system as possible, test TENS settings in clinic before home use (test at maximum output and
high/low frequencies, use lowest clinically effective setting, instruct patient not to change any settings)
Ultrasound No EMI concerns
St. Jude Medical (Hospital EMI and the Pacemaker/Implantable Cardioverter Defibrillator (ICD) Patient, personal communication)
Diathermy Avoid, even if the device is programmed off
TENS Place a magnet over the device, positioned off-centre, to suspend arrhythmia detection. A magnet reversion
will not affect the bradycardia pacing function of the device; therefore, the need for asynchronous pacing
must be evaluated OR program the device to non-tachyarrhythmia configuration, e.g. ‘Defic Off’, ‘All
Functions Off’ or ‘Brady Pacing Only’.
Programming the pacer to the bipolar mode of sensing and decreasing the sensitivity level will minimize the
potential for interaction with TENS stimulation.

Continued
856 G.C. Digby et al.

Table 2 Continued

Physical therapy modality Recommendations

...............................................................................................................................................................................
Burst mode is contraindicated
Recommendations: (i) monitor the patient’s heart rate during the procedure, (ii) electrode placement should
be left to right (lateral not anterior, posterior), (iii) place electrode pads in close proximity to each other,
(iv) maintain a high frequency (.30 Hz) at all times, (v) pacemakers utilizing impedance based sensors
(like minute ventilation or stroke volume) for rate responsive pacing should be programmed to a non-rate
responsive mode to prevent increased pacing rates during TENS therapy, (vi) following the procedure,
evaluate the pacing system by determining the capture and sensing thresholds.
Sorin Group –ELA (Diathermy Warning from User’s Manual & TENS Therapy and ICD, personal communication)
TENS Will not interfere with pacemaker or ICD with proper precautions.

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Place the TENS electrodes as close to each other as possible.
Place the TENS electrodes as far from the pulse generator/lead system as possible and monitor cardiac
activity during TENS use.
Diathermy Not recommended. If necessary, the following precautions must be used: keep the current path and ground
plate as far away from the device and the leads as possible (a minimum of 15 cm/6 in.); before the
procedure, deactivate ATP and shock therapies; during the procedure, keep the diathermy device as far as
possible from the cardiac defibrillator, set it at minimum intensity, and use it briefly; after the procedure,
check for proper implant function. The device should never be exposed directly to the diathermy source.
Therapeutic Ultrasound Not recommended

CRD patient would be best treated with regular care or by alterna-
tive means, although communication between physiotherapists and
arrhythmia services regarding appropriate treatment was found to
be practically non-existent.
Review of the literature and of the recommendations from CRD
manufacturers lead us to believe that, at the moment, the physical
therapy modalities of TENS, Diathermy, and Interferential Electri-
cal Current Therapy are best avoided in patients with CRD.
However, there is no consensus, and, furthermore, it may be poss-
ible to safely deliver these modalities in a proper setting with
device and patient monitoring, and with specific arrhythmia phys-
ician supervision. Further research regarding distance of electrode
placement from CRD, frequencies of stimulation, and sub-selecting
populations of patients with lower risk, such as non-dependent
patients with bipolar systems, may allow for these modalities to
be safely used in CRD patients. Meanwhile, acupuncture, Laser
therapy, manual therapy/traction, and US therapy appear to pose
no significant risk to patients with CRD and should be considered
as safe treatment in this patient population. Active collaboration
between physiotherapy clinics and Cardiac Rhythm Device Clinic
physicians and staff should allow the safe application of most phy-
siotherapy modalities.
Conflict of interest: C.S.S., D.P.R. and A.B. have received honor-
arium to deliver talks and conferences from Medtronic, St Jude
Medical, Boston Scientific and ELA SORIN group. A.B. has received
unrestricted grants from Boston Scientific and Medtronic. D.P.R.
has received unrestricted grants from St Jude Medical.
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857
Physiotherapy and cardiac rhythm devices

Appendix 1
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G.C. Digby et al.

Appendix 2
858
Physiotherapy and cardiac rhythm devices
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