Low frequency currents

What is electrical current?

 flow of charged particles (electros/ions) through a conductor
in to an applied electric field.
 Current is denoted as I and unit is Amperes
 Flow of electrons from –ve to +ve
 Polarity – two oppositely charged conductors: cathode (-ve)
anode (+ve)
 Voltage – electrical force which helps in moving the charged
particles from one point to other
 Denoted as V, unit is volts
 Resistance – property which resists the flows of charged particles
 Denoted as R unit is ohms
 Ohm’s law: V=I X R
 Impedance – frequency dependent opposition to current flow
Types

Alternating Pulsed/pulsatile
Direct current
current current

Interferential Premodulated
Russian
current current
Parameters
 Frequency - number of cycles or pulses per second
 expressed as Hertz for cycles or pulses per second (pps) for
pulse
 Pulse duration – entire duration from first phase of a pulse to
last phase of that pulse
 Phase duration – duration of one phase of pulse
 Interpulse interval – time between pulses
 Interphase interval – time between phases
 On/off time – as name suggests
 Usually used in context of muscle stimulation
 off time needed to relax the muscle
 Duty cycle – ratio of on time to the total time (on + off time)
 Amplitude - magnitude of current or voltage

 Modulation - pattern of variation in one or more of the

stimulation parameters.
 used to limit neural adaptation to an electrical current.
 may be cyclic or random
Direct current
 Uninterrupted, Unidirectional flow of current
 can produce polarity-based changes in the tissue, resulting in
ions being moved to and from the area.
❑ Common Techniques:
 Iontophoresis: Medication delivery
 Low voltage stimulation: Eliciting contractions from
denervated muscle.
 Direct current also known as galvanic current when used in
medical terminology
Alternating Current
 continuous bidirectional flow of charged particles.
 has equal ion flow in each direction, and as such no pulse charge
remains in the tissues.
 Most common delivered as a sine wave
 cycle is from the time that the current departs from zero current
amplitude in one direction and then crosses the zero amplitude in the
opposite direction and then return back
 wavelength is the duration of 1 cycle.
 inverse relationship between wavelength (cycle duration) and
frequency is seen in AC waveform
1 cycle
❑ Common Generators/Techniques:
 Interferential Stimulation: Pain control; muscle contractions
 Premodulated currents; Neuromuscular Stimulation: Muscle
contractions
 Pulsed current
 discontinuous current flow, in a series of pulses
 may be either unidirectional (monophasic pulsed current) eg:
HVPGS
 Bidirectional (biphasic pulsed current)

Monophasic Current

Biphasic Current
 Can be symmetric (eg; NMES) or asymmetric (balanced or
unbalanced)
 balanced pulse the charge of the phases are equal in amount and
opposite in polarity (eg: TENS)
 Unbalanced pulse the charge of the phases not equal and the net
charge also not zero. (eg; NMENS)
Therapeutic currents

Low frequency Medium High frequency

currents frequency current currents
• b/w 1 – 1000 • 1000 – 10000 • above 10000 Hz
Hz Hz • SWD
• Faradic • Interferential • MWD
• Direct/Galvanic current • Ultrasound
• TENS • Russian current
• Didynamic
• HVPGS
 Low frequency currents
 1 to 1000 Hz
 Current can stimulate sensory and motor nerves and a skin
resistance is present
 Uniphasic/biphasic
 Constant current /constant voltage
 Constant current - current remains same therefore gives
accurate results, but skin discomfort and increase of current
density
 Constant voltage – less consistent and more safer and
comfortable
 Electrical activity of Nerves
 At resting state potential difference between inside and
outside of the nerve is seen (d/t difference in conc. of ions)

 Membrane not permeable to Na ions

 Known as polarized state of nerve
 When stimulated, potential difference (PD) falls.
 At certain level, it gets permeable to sodium ions.
 This leads to difference in concentration of ions until reversal of
polarity

 This difference between the active and resting part causes the local
electron flow
 This flow is in opposite direction.
 When nerve is stimulated electrically current flow lowers the PD
and whole sequence follows along the length of nerve fiber.
 This change of polarized stage causes the travel of impulse.
 Electrical stimulation of nerves
 The membrane nearer to cathode (-ve polar electrode) is
negative and surface nearer to anode positive
 Cathode leads to potential difference because of opposite polarity
 If PD falls a certain level nerve impulse is generated
 Anode can also generate but the farther portion of nerve

Clinical Application: Active electrode should be cathode that can help in contraction wit
less current as required in anode
 Accommodation
➢ Adaptation of nerve when constant current flows
➢ A current that rises/falls suddenly more effective in initiating an
impulse

 Effects of nerve stimulation

➢ On stimulation of sensory nerve downward impulse has no effect but
upward impulse is appreciated
➢ Long duration impulses produce uncomfortable and stabbing
sensation but less duration gives only mild prickling sensation
➢ On stimulation of motor nerve downward impulse passing through
muscle leads to muscle contraction
➢ On stimulation of motor nerve trunk impulses pass to all the muscles
➢ When current is applied on particular muscle maximum response is
seen at motor point (point at which main nerve enters muscle)
 Effect of Frequency of Stimulation
➢ Single stimulus applied per second produces sudden brisk
contraction followed by immediate relaxation.
➢ Increase in the frequency of stimuli shortens the period of
relaxation.
➢ At frequency = 20 Hz, no relaxation occurs partial tetany is seen
➢ At more than 60 Hz, there is no relaxation at all contraction is
fully tetanic
➢ A difference b/w physiological and electrical contraction is that
with physiological contraction slow twitch fibers are contracted
first but with electrical contraction reverse occurs.
➢ Therefore when applied clinically longer rest times are needed
➢ Also both electrical contractions and physiological contractions
are needed for good functional rehabilitation
 Strength of Contraction
➢ It depends on:
1. Quantity of motor nerve activated
2. Rate of change of current.
 If current rises suddenly, less intensity is required for muscle
contraction as no time for accommodation but if current
rises slowly greater intensity is required as in trapezoidal,
triangular current, etc.
 Electrical stimulation contraction is based on overload an
specificity principle (fast twitch fibers contracted first)
 Therefore till 12 weeks stimulation electrically is beneficial in
increasing the strength
 Faradic current
 short duration interrupted direct current with pulse duration of
0.1–1 ms and frequencies between 50–100 Hz,
 used for the stimulation of innervated muscles
 The term faradism was used to signify the current produced by
the first faradic coil
 It is uneven low frequency alternating current
➢ Low intensity long duration
➢ High intensity short duration

Pure faradic
current
 Now a days electrical stimulator are used

 Surged faradic currents – modified for better results

 Surging produces a near-normal tetanic-like contraction and
relaxation of the muscle
 Various forms are available
 Physiological effects of faradic type
current
 Current travels in tissues with low resistance
 Stimulation of sensory nerves
➢ Mild prickling sensation due to stimulation of sensory nerves
➢ A reflex vasodilatation caused leading to erythema
 Stimulation of motor nerves
➢ leads to contraction of muscles
➢ Surged current is used
 Effects of muscle contraction
➢ Increased metabolism (increase in oxygen, increase output of waste
products)
➢ Increased blood supply
➢ Increased venous and lymphatic return
 Stimulation of denervated muscles
➢ Faradic type current cannot be used as intensity required
would be too high (not tolerable) because of short duration
 Chemical effects
➢ If current is applied through an electrolyte
Indications
1) Facilitation of the muscle action
 In assisting voluntary contraction
 Pain leads to inhibition of muscle contraction
 So, electrical stimulation of motor neurons reduce the inhibition of
muscle contraction and also helps in inducing relaxation to its
antagonists
 Initially treatment in pain-free range. Patient is advised to produce
voluntary contraction along with the stimulation
 The amount of voluntary contraction is increased gradually and
electrical stimulation is reduced until the muscles produce full
voluntary contraction
2) Re-education of muscle action: Inability to contract the
muscle can be due to:
i. Prolonged disuse –flat foot (intrinsic muscles)
ii. Incorrect use – hallux valgus (adductor hallucis muscle)
 faradic stimulation may be used to restore the movement
 Active contractions should be attempted at the same time along with
the electrical stimulation.
3) Training a new muscle action:
i. Tendon transplantation surgery
ii. Reconstructive operations.
 A different or new action is to be taught muscle is stimulated in a
new pattern.
 During this treatment the patient must concentrate on a new
movement and try to assist it along with voluntary contractions
 Takes longer time than re-education
4) Loosening and prevention of adhesion:
 Effusions in the tissues leads to adhesion.
 Active exercise when not possible, electrical stimulation in the
form of faradic current may be used to prevent adhesions.
5) Improvement in venous and lymphatic drainage:
 Alternative contraction and relaxation of muscles produces
pumping action helping in effective venous and lymphatic
drainage
 Faradism under pressure, can be used
 A very effective treatment of edema and gravitational ulcer

Neuropraxia Axonotmesis Neurotmesis

• Contusion of nerve • Axons are damaged but • Nerve is completely

• Anatomically nerve endoneural tubes remain cut/disorganised
preserved intact • Wallerian degen in both
• Temp. physiological • Intact epi, peri and distal and proximal part
disruption of conduction endoneurium • Neuroma formation may
• No wallerian degeneration • Wallerian degeneration in occur needing surgery
• Complete recovery within distal part • Poor prognosis
3-6 weeks • Partial to complete recovery
in 3-6 months (eg: fractures
and dislocations)
6) Neuropraxia of a motor nerve:
 Impulses from brain are not able to reach up to the muscles
through site of lesion.
 Although no degeneration of nerve so if stimulation takes
place below the site of lesion, the impulses will easily pass
 Electrical stimulation is not usually necessary because
recovery takes place with any marked changes in the muscle
tissue.
7) Severed motor nerve:
 When any nerve is damaged severely degeneration of axons takes
place
 Degeneration takes several days to complete, and for a few days
after the injury a muscle contraction may be obtained by faradic
type current.
 So, during this duration faradism can be used
 But once good response can’t be obtained from faradic current
muscles can be stimulated by interrupted direct current or
modified direct current.
 Techniques of Treatment
1) Preparation of apparatus
 Stimulator with automatic surging is used
 Therapist should first test the equipment
 Ensure equipment is no where close to any operating short
wave equipment (to prevent output disturbance from radio-
frequency energy.
 Educate the patient about the sensation he/she should feel
 Lint/sponge with at least 8 layers should be used along with
electrode (should be folded evenly)
 Pads/lint are soaked in 1% saline (reduces the resistance of
solution)
2) Preparation of patient
 Clothing is removed over the treatment area and part should be
in comfortable position
 Skin of the treatment area should be washed with soap and water
to remove natural oil
 If skin has breaks they should be appropriately covered to
prevent any discomfort
 Indifferent pad should be large to reduce current density and
prevent excessive skin stimulation
Stimulation of motor points
 Skin surface areas in the muscle that are hypersensitive to
electrical current flow.
 Motor nerves and blood vessels enter the muscle mass in this area
 Stimulation of these points elicits a stronger contraction at lower
intensities (due to low electric resistance).
 Used when stimulation of particular muscle is required eg: Vastus
Medialis in Quadriceps lag
 Along with stimulation voluntary contractions can be attempted
 Mostly motor points are located at the junction of upper one third
and lower two third of the fleshy belly of the muscle except n
some cases
 Deep muscles can be stimulated where they emerge superficially
 Motor points of
face

Motor points of back

 Motor
points of
lower
extremity
Motor points of upper
extremity
Stimulation of muscle groups
 Usually in those cases where a particular action is carried
mostly by a group of muscles eg: quardiceps, intrinsic
muscles of foot, pelvic floor muscles.
 While stimulation of quadriceps knee is in flexion. One
electrode is placed over femoral nerve and other electrode
over motor point
 Faradic foot bath
 when stimulation of foot is done in the water
 Water gives good contact, prolonged soaking decreases
resistance of the skin
 Indications - Flat foot (Pes Planus), Chronic retrocalcaneal
bursitis, hallux valgus, Metatarsalgia, Plantar fascitis,
Calcaneal spur etc.
 Difficult to stimulate foot muscles by using motor points
technique as there are 4 layers of foot muscles
 Patient position: high sitting with back support
 Place the foot in the bath
 Level of water should be at the web of toes
 Level above this will stimulate dorsal muscles
 For lumbrical muscles: place electrode under the heel and
metatarsals head transversely
 Plantar interossei muscles: one electrode on each side of the
foot at the level of metatarsals shaft
 Abductor hallucis: pad electrode under the heel and active
elctrode on the muscle belly of abductor hallucis
 Surge faradic current will be used
 Relaxation period should be larger than the contraction period to
avoid fatigue
 Intensity: tetanic contraction
 Patient encouraged to contract muscles voluntarily
 Discontinue when voluntary contraction seen
 Contraindications – foot infection, pes cavus, open unhealed
wound
 In case of stress incontinence and prolapse of pelvic organs
pelvic floor muscles may be stimulated using vaginal/rectal
electrode as active electrode
 Passive electrode can be laced over lumbosacral area
 Duration of treatment should be short as these muscles are
thin and can get fatigue easily
Faradism under pressure
 Application of surge faradic current combined with the elastic
crepe bandage to reduce swelling and edema of distal extremities
 elastic crepe bandage increases the pressure on the vessels when
the muscles contract in response to electric stimulation
 Position is such that limb is elevated
 Electrode is mostly placed over the muscles which act in pumping
action for eg: calf muscles for lower extremity and flexors of arm
and forearm in upper extremity
 Rate of contraction is slow and frequency also should be low
 Stimulation through motor points may be difficult so nerve
stimulation may be used
 Total treatment time should be 30 minutes
 U/E : supine position with arm elevated above the heart level
to enhance venous return
 Remove all the jewellery
 Clean the flexor aspect of the arm and forearm with soap and
warm water to reduce skin resistance
 Place pad electrodes over flexor aspect of arm and forearm
 Apply an elastic crepe bandage from distal to proximal
(pressure decreases gradually towards the arm)
 No gaps should be there between the turns of the bandage
 L/E : supine position with involved leg elevated above the
heart level to enhance venous return
 Remove all the jewellery
 Clean the posterior leg and the plantar surface with soap
and warm water to reduce skin resistance
 Place pad electrodes over mid calf muscles and other pad
electrode over the plantar aspect of the foot
 Apply an elastic crepe bandage from distal to proximal
(with max. pressure at the toes of the foot, pressure
decreases gradually towards proximal calf muscles)
 No gaps should be there between the turns of the bandage
 The level of stimulation can be adjusted by a handheld remote
control, which also allows the patient to turn the device off and
on
 have a positive effect on brain plasticity with its provision of
high-level sensory-motor input into the CNS
 Limitations:
 Muscle fatigue with stimulation that limits the duration of
standing
 The presence of hypertonia, spasms and joint contractures that
alter joint torques and thus limit functional movements
 The high energy cost of walking with such a device; and
 The time taken to don and doff the system
Interrupted direct current / Galvanic
Current
 When unidirectional current is interrupted, series of pulses
or phases of unidirectional current rises
 Pulse duration – 300 to 600ms, 100 ms usually used
 Frequency – 30/minute
 Depolarized form – in some equipment low intensity
reversed current also passes between two pulses
 Direct current leads to chemical changes
Modified direct
current
waveforms
Physiological effects
 Denervated muscle can be stimulated
 Current rising gradually is effectively
 Brisk contraction of innervated muscles and sluggish
contraction of denervated muscles is seen (depends on
temp.)
 Stabbing/burning sensation occurs due to stimulation of
sensory nerves esp. C fibers due to long duration
 Reflex vasodilatation and erythema seen
 Contraction of denervated muscle
 Treatment duration should be till fatigue
 In early stages of re-innervation stimulation can be used with
short duration currents like faradic currents
 Waveform with gradual increase in current should be selected
Application
 Placement
➢ passive electrode over origin of muscle and active over insertion (stabile
technique)
➢ Passive electrode over origin and active stroked over the muscle fibers
(ensure proper contraction and less skin irritation) (labile technique)
 Disadvantage – when many muscles need to be stimulated, impractical
 Polarity of electrode need to be determined
 The pH of tissues under the cathode (negative pole) becomes basic (the
alkalinity of the tissues is increased), increasing the risk of chemical
burns.
 Acids collect under the anode that can cause coagulation of proteins and
hardening of the tissue.
 Wound healing through electrical
stimulation
 Healing has three phases

Inflammatory Proliferative Maturation

• redness, edema, • (+) of • Collagen
warmth, pain, fibroblasts remodelling
and decreased • DNA and
ROM collagen syn.
• Angiogenesis
 Processes that take place while electrical stimulation

Altering cell membrane activity

Oedema reduction

Increased antimicrobial activity

Alteration in electrical potential

Improving tissue oxygenation

Promote circulation (not so clear)

 Mechanism
Calcium channels open up

Entry of calcium in the cell

Takes place at 60-90 V Insulin receptors open up

Stimulation of fibroblasts, Syn.of DNA

and collagen
 While stimulation tissue attracts:
➢ Neturophils
➢ Macrophages
➢ Lymphocytes
➢ Fibroblasts
 Process k/s galvanotaxis
 • Active neutrophils
• Lymphocytes
Negative polarity (early • Platelets
infection/inflammation) • Mast cells
• Keratinocytes
• Fibroblasts

• Inactive neutrophils
• Macrophages
Positive polarity • Epidermal cells
(proliferative stage)
 HVPGS
 High-voltage pulsed galvanic stimulation (HVPGS)
– monophasic current
 A typical HVPS generator produces a twin-peaked
waveform or a train of two single pulses having a
short phase duration and a long interpulse interval.
 wide variety of uses, including muscle reeducation, nerve
stimulation, reduction of edema, and pain control
 The short phase duration allows for the activation of sensory and
type II motor nerves at a low output intensity (voltage) without
stimulating pain fibers.
 The interpulse interval is much longer than the pulse duration.
 Therefore no skin significant pH changes occur
Parameters
 CURRENT TYPE: Monophasic
 AMPLITUDE: 0–500 mA
 VOLTAGE: 0–500 V (150 to 500 V)
 PULSE FREQUENCY: 1–120 pps (Low frequency stimulate
endorphin release for pain control, moderate levels produce
tetanic contractions, and the upper levels are useful in
activating the gate mechanism of pain control)
 PULSE DURATION: 13–100 μsec
 Indications
➢ Delay of denervation and disuse atrophy by stimulating muscle
contractions
➢ Reduction of post-traumatic edema
➢ Increase in local blood circulation (unsubstantiated)
➢ Restoring range of motion
➢ Reduction of muscle spasm
➢ Inhibition of spasticity
➢ Reeducation of partially denervated muscle
➢ Facilitation of voluntary motor function
➢ Wound healing
➢ Pain relief
Application
 applied using either a monopolar or bipolar technique.
 Monopolar application is used when the focus of the
treatment is over a wide area, such as in sensory-level pain
control, and finite areas when point stimulation probes are
used.
 A bipolar technique is often used when attempting to evoke a
contraction from a specific muscle or in motor-level pain
control.
Physiological Effects
1) Neuromuscular Stimulation
 The most important role for HVPS in neuromuscular
stimulation is of muscle re-education, after periods of
immobilization or transient denervation.
 As it has short phase duration, a moderately high intensity
muscle contraction with relatively little patient discomfort
can be given.
2) Pain control
 Can be used for both acute and chronic pain through both
gate control and/or opiate release
3) Oedema reduction
 In acute cases cathode is used as active electrode because it repels
negatively charged serum proteins, essentially blocking their
movement out of blood vessels. The injured limb should be
elevated or a compression wrap should be given
 In sub acute and chronic stages muscle contraction (pumping
action) is used to reduce the oedema. Electrode placement can be
over the motor points of the major muscle groups.
 Limb elevation enhances the effectiveness of the treatment
 However other currents are more beneficial in subacute and
chronic stages
 PARAMETERS FOR ELECTRICAL
STIMULATION FOR EDEMA CONTROL
 Polarity - Negative
 Pulse Frequency - 100-120 pps
 Pulse Duration - 40-100 ms
 Amplitude – producing comfortable tingling sensation
 Treatment Time – 20 to 30 min
 Electrode Placement - directly over the area of edema, with the
dispersive electrode placed over another large flat area that is
generally proximal to the area of edema
4) Increased blood flow
 Increase in muscle contraction leads to increased metabolism
5) Wound healing
 Mainly used to promote healing of decubitus ulcers and surgical
incisions.
 Occurs through antimicrobial effect increase of leukocytes,
epidermal cells, and fibroblasts and the level of collagenase
 Negative polarity encourages blood clots to dissolve and increases the
inflammatory/hemorrhagic by-products, promoting the healing of
necrotic tissues.
 Clot formation around the margin of the wound and in granulation
tissue is promoted by a positive polarity
 Kloth recommended – negative polarity for first 3 to 7 days ,
thereafter positive polarity
 Was used by Kloth and Feedar in 1988 for patients with stage
IV decubitus ulcers
 Study had total of 16 patients , (n=9 in t/t group) and (n=7
in sham t/t group) ranging in age 20 to 89 years
 t/t group was given monophasic twin pulse of 105 pps at
(100-175 V) for 45 mins/ day for 5 day/week.
 In sham t/t group machine output was kept at ‘0’
 100 % healing was seen in t/t group in 7.3 weeks with
44.8% per week whereas in sham t/t group as 29% over 7.4
weeks and average of 11.6% per week
 In another study by Griffin et al (1991), patients with
pressure ulcer in SCI were taken
 Total 17 patients were taken in t/t group was given t/t for 1
hour/day for 20 days at 100 pps, 200 V
 80% reduction in size of pressure ulcer was seen
 In another study by Houghon et al in 2003 took 27 patients
with chronic leg ulcers, an RCT was done
 t/t group was given current at 150 V, 100pps, 100µsec, 45
mins, 3 sessions/week for 4 weeks
 There was reduction by 44%
 Parameters of electrical stimulation
 Waveform – monophasic waveform
 Electrode Placement - Treatment electrodes may be placed in or
around the wound
 Polarity – as per the phase of wound
 On : Off Time - delivered continuously . This maximizes the
amount of charge delivered and thus the attraction of charged
particles
 Current Amplitude - comfortable sensation should be felt
without a motor response.
 In case of decreased or altered sensation the appropriate
amplitude can be determined by applying the electrode to
another area.
 Pulse duration – 40 to 100 µsec
 Pulse frequency – 100 to 125 pps
 5 days/week for 45-60 min duration each day
Alternate methods of application
1) Water Immersion
 to treat irregularly shaped areas, such as
the hand or foot
 the water serves as the active electrode
 For safety, rubber electrodes can be
used for the immersion with the
insulated (rubber-coated) side facing
toward the body part
 After treatment for oedema reduction,
the treated limb should be wrapped and
elevated to encourage venous return.
2) Probe
 to specifically stimulate trigger points or other localized areas.
 serves as a very small active electrode in a monopolar configuration
with high current density being placed on a limited group of tissues.
 A dispersive electrode is required to complete the circuit. A typical
probe consists of a handle with a metal tip that is designed to hold a
conductive medium
 The handle contains an INTENSITY control knob and an INTERRUPT
button.
 The probe is activated by setting the electrode alternating switch to
PROBE or by plugging the probe into a separate jack on the generator.
 PRECAUTIONS
 Cardiac disease
 Impaired mentation or sensation
 Malignant tumors
 Skin irritation or open wounds
 CONTRAINDICATIONS
 Demand pacemaker or unstable arrhythmias when electrical
stimulation is delivered with a stimulation unit
 Over the carotid sinus
 Venous or arterial thrombosis or thrombophlebitis
 Pelvis, abdomen, trunk, and low back during pregnancy
 Practical
 Electrodes should not be placed directly over bony
prominences. (resistance, discomfort, burns)
 Space b/w electrodes
 Alcohol should not be used to clean the skin (can dry the skin
excessively, reducing electrical conduction, and alcohol that
remains on the skin can accelerate breakdown of the gel on
electrodes)