Expert Review of Medical Devices

ISSN: 1743-4440 (Print) 1745-2422 (Online) Journal homepage: https://www.tandfonline.com/loi/ierd20

Medical devices to deliver transcutaneous

electrical stimulation using interferential current
to treat constipation

Bridget R Southwell

To cite this article: Bridget R Southwell (2013) Medical devices to deliver transcutaneous
electrical stimulation using interferential current to treat constipation, Expert Review of
Medical Devices, 10:6, 701-704, DOI: 10.1586/17434440.2013.855507

To link to this article: https://doi.org/10.1586/17434440.2013.855507

Published online: 09 Jan 2014.

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 Editorial

Medical devices to deliver

transcutaneous electrical stimulation
using interferential current to treat
constipation
Expert Rev. Med. Devices 10(6), 701–704 (2013)

Bridget R “…interferential current has been used to treat a number of

Southwell
Murdoch Childrens Research
Institute, Royal Childrens
Hospital, Melbourne, Australia
and
Department of Paediatrics,
University of Melbourne,
Melbourne, Australia
bridget.southwell@mcri.edu.au
bowel motility disorders including dyspepsia, irritable bowel
syndrome, slow transit constipation in children and adults and
constipation in children with myelomeningocele…”
Transcutaneous electrical stimulation
(TES) is a well-known method used by
physiotherapists to treat pain and muscle
injury. Interferential current (IFC) is a
special type of TES using two currents
that cross and produce a beating effect [1].
TES-IFC has been used for over 20 years
to treat bladder over-activity and urinary
incontinence and to strengthen the pelvic
floor [2–5]. When used for urinary inconti-
nence, TES also produced diarrhea, lead-
ing physiotherapist Janet Chase, who
specialized in incontinence, to test TES
on children with chronic constipation [6].
Since that study, published in the year
2005, IFC has been used to treat a num-
ber of bowel motility disorders including
dyspepsia [7], irritable bowel syndrome [8],
slow transit constipation in children [9–14]
and adults [11] and constipation in chil-
dren with myelomeningocele (a type of
spina bifida) [15]. In the colon, TES-IFC
increased the colonic motility, sped up
colonic transit, increased the sensation of
the urge to defecate, increased the defeca-
tion frequency and reduced soiling
and bloating.
There are many TES devices on sale.
Physiotherapists use devices that are
plugged into AC (220/240 V) power.
Battery-operated devices that can be
used at home are available on the
Internet. There is a wide range of qual-
ity products available but only a few are
able to deliver IFC.
Our initial studies on constipation
used a device, common in physiotherapy
clinics, the Metron Vectorsurge (Aus-
tralia). This device can deliver current
via two or four electrodes. It delivers
interferential, premodulated, TENS and
Russian stimulation. It delivers IFC at
2500, 4000 or 10,000 Hz carrier fre-
quency. This device is plugged into the
AC power supply and allows complete
control by the clinician. Because it is
difficult for patients to attend clinic
every day, treatment was given three-
times a week for 20 min and the total
number of sessions was 12. Using the
stimulation parameters that produced
diarrhea during bladder treatment, we
gave stimulation using two channels
(channel one at 4000 Hz, channel two
varying from 4080–4150 Hz, at a com-
fortable setting of 20–30 mAmps) using
4 cm  4 cm carbon rubber electrodes.
TES-IFC increased defecation and
stopped soiling in five of eight children
with chronic constipation and improve-
ments lasted for more than 3 months in
some children [6]. In a larger group,
there were similar improvements and a
slight increase in transit speed and

KEYWORDS: bowel motility • electrotherapeutics • physical therapy • physiotherapy

www.expert-reviews.com 10.1586/17434440.2013.855507 Ó 2013 Informa UK Ltd ISSN 1743-4440 701

 Editorial Southwell
improved quality of life [9–10,16]. Colonic contractions increased [16]
and improvements lasted up to 2 years [17]. A recent detailed
review of our studies is available free online [101].
Battery-operated IFC devices became available in the mid-
2000s. With these, the patient/parent can give stimulation at
home, allowing daily stimulation for a longer time (commonly
1 h). Eleven children, who previously had stimulation three-
times a week without success, underwent daily treatment for
2 months, leading to an increase in defecation frequency into
the normal range in nine children [12]. In a larger group of
32 children, with treatment-resistant constipation, when given
daily stimulation for 3–6 months, more than half of the chil-
dren showed increased defecation into the normal range and
stopped soiling [13].
Three battery-operated IFC devices have been reported for
bowel stimulation. Firstly we used Fuji Dynamics IF
4160 (Hong Kong). From the year 2008–2012, we used the
model FD09. This delivered current from a 9 V rechargeable
battery. In the mid of 2012, a new model was released, FD-10,
that uses four 1.5 V single-use batteries or can be plugged into
AC power. We only used the FD-10 on AC power to provide
enough current for 1 h of treatment. This device is available in
Australia and UK. Other groups have used NOVIN model
510 A (Isfahan, Islamic Republic of Iran) [15,18] and Ito
EU-940 (Germany) [8] with good results. A comparison among
the output of the devices would be useful.
Electrical current delivery depends on the electrodes and
many types are available. Electrodes can be long-use types
made of carbon rubber and used with suction [8] or with wet
sponge pads [6] or can be silicon-coated disposable electro-
des [13]. Different sizes have been used including 2.3  3.5 cm
and 4  4 cm. They have been placed with two electrodes on
the front and two on the back, at the level of the belly button
[8–10,13,15–16,101] or over the lower pelvic zone [18] or with four
on the back [7]. For home use, it is important that patients
should be trained in electrode use. If they use disposable elec-
trodes, it is important that they are sticky and should create a
good contact with the skin. Body hair should be removed for
best results.
To produce the highest level evidence, randomized-control
trials (RCTs) are required. Two RCTs have been
performed [9–10,15]. It is not easy to perform a blinded study for
a treatment that can be felt by the patient, that lasts for
months and is delivered at home by the patient. Some of the
major points of concern are: How can you blind the person
delivering the treatment?; How can you blind the patient?;
What placebo can be used?; and what features can be measured
to get an objective measure of improvement? Patients can
record through diaries but for the evidence-base it is preferable
to have objective measures also. Those measures used so far,
include transit studies [16], gastric emptying [7], anorectal man-
ometry [15] or colonic manometry [16] to measure the rate of
movement through the bowel or strength or frequency of con-
tractions. Questionnaires are also used to measure the changes
in bowel symptoms or quality of life [9,15].
702
User difficulties
For home-use, it is important that patients are trained to use
the device correctly. Physiotherapists are trained to use the elec-
trical therapy but for other clinicians, we found that it takes 5–
10 patients to learn what to do. Ian Yik, a surgeon, reported
that it took six patients for him to learn how to teach them, to
use the portable machine correctly and to make sure that the
patients had recorded their daily diary and passed it to the
clinician [13]. We have surveyed patients and found that they
have problems in choosing the right settings on devices and
may connect the leads incorrectly so that currents do not cross.
Mechanism of action
It remains to be determined whether TES-IFC is acting via spi-
nal pathways, sensory nerves, enteric nerves, interstitial cell of
Cajal or hormonal systems. Motor control of the intestine is
very complex [101]. Motor activity of the gut is determined by
muscle cells, pacemaker cells (interstitial cells of Cajal), nerves
and hormones. The intestine contains its own nerve cell net-
work (the enteric nervous system) and has connections to the
Central Nervous System (CNS) via the vagal, splanchnic and
pelvic nerves. These carry sympathetic, parasympathetic and
sensory nerve fibres [19]. Sympathetic innervation inhibits bowel
motility, while parasympathetic innervation activates the
bowel. [20]. Spinal nerves (S2-4) carry parasympathetic outflow
to the rectum and internal anal sphincter, somatic innervation
to the anal sphincter muscle (striated muscle) and sensory fibres
to the CNS [19]. Direct electrical stimulation of these nerves
(using implanted electrodes) is sufficient to activate bowel
motility reflexes. For example, in patients with spinal injuries,
sacral nerve stimulation initiates colonic contraction producing
movement of feces into the anal canal, resulting in reflex pelvic
floor relaxation and evacuation of the rectum [20]. TES-IFC
would be expected to stimulate these nerves, but might also
have effects within the intestine. Animal models are needed to
investigate the mechanism of action.
Ward has studied IFC and thresholds for sensory nerves,
pain and muscle contraction. He presented a detailed discus-
sion of the myths and realities of IFC [1]. Interferential stimula-
tors produce two independent currents applied by two pairs of
electrodes, positioned diagonally. It is commonly claimed that
there is a maximum stimulation in the region of intersection of
the currents but Ward argues that the stimulus experienced by
a nerve fiber may be continuous (unmodulated), fully modu-
lated or partially modulated depending on the fiber location
and orientation relative to the electrodes. The stimulation
intensity experienced by nerve fibers has a maximum modula-
tion if the fibers are oriented optimally and zero modulation
when fibers are oriented along one of the current pathways [1].
Ward showed that stimulation of nerves that innervate striated
muscle at 100 Hz or more, results in fatigue and reduction in
torque in the muscle and can also inhibit the release of acetyl-
choline [21]. Ward also showed that that premodulated IFC,
delivered via two large electrodes, may be clinically more effec-
tive than the traditional true IFC arrangement in terms of
Expert Rev. Med. Devices 10(6), (2013)
 Transcutaneous electrical stimulation to treat constipation Editorial

depth efficiency, torque production and patient comfort [22].
None of these factors have been measured for abdominal stim-
ulation and bowel activity.
Future perspective
Transcutaneous stimulation of the intestine is a new use for
an established but poorly characterized or understood
method. In the next 5 years there should be an expansion in
its use to increase intestinal motility and with that, many of
the parameters for its use and mechanism of action should be
addressed. This is a new field and there are many unknown
opportunities for improvement in devices and treatment
parameters. There are still many issues to resolve about the
optimal use of IFC devices for bowel motility, including cur-
rent settings, electrode position and treatment frequency.
These aspects require active study. There is also much scope
for future improvements in devices that are easier for patients
to use, feedback that electrodes are delivering adequate cur-
rent or which ones are not, determining optimal placement
of electrodes, and for studies that determine where current
goes, what are the best electrical parameters for stimulation,
what time of day is best to do stimulation and which patients
will benefit from IFC treatment.
It looks like TES-IFC could be a useful treatment for
patients with bowel motility disorders and should add to the
techniques available especially for treatment-resistant patients.
The method can be used for children and the elderly, it is
cheap (<US$500), non-invasive and has no side effects. We
will also see the development of devices specifically for use on
the bowel in the next few years.
Financial & competing interests disclosure
BR Southwell holds patents on the method of transcutaneous electrical
stimulation to treat constipation. She has received Australian Government
National Health and Medical Research (NHMRC) grants to study the
effect of transcutaneous electrical stimulation on children with slow-transit
constipation and with anorectal retention and to develop an electrical
stimulation device specifically to treat constipation. She has received invest-
ment from the Medical Research Commercialization Fund to develop the
device and created a startup company – GI Therapies (Melbourne,
Australia) – to develop and test a prototype device. The author has no
other relevant affiliations or financial involvement with any organization
or entity with a financial interest in or financial conflict with the subject
matter or materials discussed in the manuscript apart from those disclosed.
No writing assistance was utilized in the production of this manuscript.

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