Model of Electrotherapy

Electrotherapy modalities follow a very straightforward model that is presented

below.
In principle, the model identifies that the delivery of energy from a machine or
device is the start point of the intervention.
The energy entry to the tissues results in a change in one or more physiological
events. Some are very specific whilst others are multifaceted.
The physiological shift that results from the energy delivery is used in practice to
generate what is commonly referred to as therapeutic effects.

A simple model of Electrotherapy

The clinical application of the model is best achieved by what appears to be a

reversal of this process.
Start with the patient and their problems, identified from the clinical assessment.
Once the problems are known, the treatment priorities can be established and the
rationale for the treatment determined.
Knowing what it is that is intended to be achieved generates the target for the
intervention. Moving one step back through the model, the question then arises
if that is the intended outcome or therapeutic effect, which physiological
processes need to be stimulated, modified or affected in order for the outcome to
be achieved?
Once the physiological changes are established, one further step back through the
model will enable the determination of the most appropriate modality that can be
used to achieve this effect.
The effects of electrotherapy appear to be modality dependent. This is a critical
decision, in that some modalities have a limited sub set of effects which are
fundamentally different from another modality.

Having identified the modality that is best able to achieve the effects required, the
next clinical stage is to make a dose selection.
Not only is it critical to apply the right modality, but it needs to be applied at the
appropriate dose in order for maximal benefit to be achieved. An obvious
example might be Laser Therapy. Applied at low dose, laser has effects when
treating a variety of open wounds and musculoskeletal tissue problems. Applied at
a higher dose, the same light energy is used by the surgeon as a means to ablate
tissue.
This fundamental model used to explain electrotherapy could be applied to many
interventions drug therapy, manual therapy, exercise therapy.
But electrotherapy is little different from manual therapy or anything else in the
treatment realm. It is a tool that when applied at the right time at the right dose
and for the right reason has the capacity to be beneficial.
Applied inappropriately, it is not at all surprising that is has the capacity to
achieve nothing or in fact to make things worse.
The skilful practitioner uses the available evidence combined with experience to
make the best possible decision taking into account the psycho-social and holistic
components of the problem it is not a simple reductionist solution.

Current Concepts in Electrotherapy Tim Watson (2008) Page 1

Current Concepts in Electrotherapy

Much as electrotherapy has been a component of physiotherapy practice since

the early days, its delivery has changed remarkably and continues to do so.
Modern electrotherapy practice needs to be evidence based and used
appropriately. Used at the right place, at the right time for the right reason, it
has phenomenal capacity to do well.
Used unwisely, it will either do no good at all, or worse still, make matters
worse.
The skill of electrotherapy is to make the appropriate clinical decision as to
which modality to use and when.
The term Electrotherapy in this context is used in the widest sense. Strictly
speaking some modalities (Ultrasound for example) do not strictly fall into an
electrotherapy grouping, which is why some authorities prefer the term
Electrophysical Agents which would encompass a wider range.
For the sake of ease, Electrotherapy will be used throughout this
documentation, but acknowledged that it could be challenged as a term.
All electrotherapy modalities (with the exception of biofeedback) involve the
introduction of some physical energy into a biologic system. This energy
brings about one or more physiological changes, which are used for
therapeutic benefit.
In the clinical environment, there are two additional jobs to do: firstly to
select the most appropriate dose of the therapy and then lastly to apply the
treatment. Generally speaking, the delivery of the therapy is relatively
straightforward. The dose selection however is critical in that not only are the
effects of the treatment modality dependent, but they appearing to be dose
dependent as well.

In other words, it is important to select the most appropriate modality based on

the available evidence, but also to deliver it at the most effective known dose.
There are many research publications that have identified a lack of effect of
intervention X, yet other researchers have shown it to work.

Electrotherapeutic Windows
Windows of opportunity are topical in many areas of medical practice and are
not a new phenomenon at all.
It has long been recognised that the amount of a treatment is a critical
parameter.
There are literally hundreds of research papers that illustrate that the same
modality applied in the same circumstances, but at a different dose will
produce a different outcome.
The illustrations used here are deliberately taken from a range of studies with
various modalities to illustrate the breadth of the principle.
Using a very straightforward model, there is substantial evidence for example
that there is an amplitude or strength window.
An energy delivered at particular amplitude has a beneficial effect whilst the
same energy at lower amplitude may have no demonstrable effect.
Papers by Larsen et al (2005) measuring ultrasound parameter manipulation in
tendon healing, Aaron et al (1999) investigating electromagnetic field
strengths, Goldman et al (1996) considering the effects of electrical
stimulation in chronic wound healing, Rubin et al (1989) investigating
electromagnetic field strength and osteoporosis and Cramp et al (2002)
comparing different forms of TENS and its influence on local blood flow all
provide evidence in this field.
Along similar lines, frequency windows are also apparent. A modality
applied at a specific frequency (pulsing regimen) might have a measurable
benefit, whilst the same modality applied using a different pulsing profile may
not appear to achieve equivalent results.
Electrical stimulation frequency windows have been proposed and there is
clinical and laboratory evidence to suggest that there are frequency dependent
responses in clinical practice. There are also several authors who appear to
have demonstrated that frequency parameters are possibly less critical,
especially in clinical practice, and examples can be found in the literature on
TENS and Interferential Therapy.
A simple therapeutic windows model is illustrated in the figure alongside,
using amplitude and frequency as the critical parameters.
The ideal treatment dose would be that combination of modality amplitude
and frequency that focuses on the central effective zone.
It can be suggested (from the evidence) that if the right amplitude and the right
frequency are applied at the same time, then the maximally beneficial effect
will be achieved.
Unfortunately, there are clearly more ways to get this combination wrong
than right.
A modality applied at a less than ideal dose will not achieve best results.
Again, this does not mean that the modality is ineffective, but more likely, that

the ideal window has been missed. The same principle can be applied across
many, if not all areas of therapy.
The position of the therapeutic window in the acute scenario appears to be
different from the window position for the patient with a chronic version of
the same problem. A treatment dose that might be very effective for an acute
problem may fail to be beneficial with a chronic presentation
Given the rapidly increasing complexity simply by using a two parameter
model amplitude and frequency) with two levels of condition (acute and
chronic), it is easy to see how difficult the clinical reality might be.
If this methodology is pursued, it is interesting to note how the effective
treatments cluster when plotted, adding weight to the therapeutic windows
theory.
Assuming that there are likely to be more than two variables to the real world
model, some complex further work needs to be invoked. There is almost
certainly an energy or time based window (e.g. Hill et al 2002) and then
another factor based on treatment frequency (number of sessions a week or
treatment intervals).

The Body Bioelectric

The electrical activity of the body has been used for a long time for both
diagnostic and monitoring purposes in medicine, largely in connection with
the excitable tissues. Examples include ECG, EMG, EEG.
More recent developments have begun to look at the tissues which were not
regarded as excitable, but in which, endogenous electrical activity has been
demonstrated.
The relationship between endogenous electrical activity (not exclusively
potentials), injury & healing have been researched in several areas of clinical
practice and has been well documented in several publications, including
Watson (2002, 2008).
The subject of endogenous bioelectricity is somewhat larger than can be
detailed, though there is one important link between regular electrotherapy and
endogenous bioelectrics identified below.
The Bioelectric Cell
Every living cell has a membrane potential (of about -70mV), with the inside
of the cell being negative relative to its external surface.
The cell membrane potential is strongly linked to the cell membrane transport
mechanisms in that much of the material that passes across the membrane is
ionic (charged particles), thus if the movement of charged particles changes,
then it will influence the membrane potential. Conversely, if the membrane
potential changes, it will influence the movement of ions.
Relative to the size of the cell, the membrane potential is massive. The
membrane is, on average 7-10 nm thick (a nanometer is a thousandth of a
millionth of a meter).
The equivalent voltage is somewhere in the order of 10 million volts per metre
(which is reasonably impressive!).

The energy in the membrane (and other organelles of course) offers the
potential (no pun intended) to change the behavior of the cell and therefore
make a difference to the behavior of cells and tissues.
That different cells and tissues respond preferentially to different types of
energy and at different doses should be no surprise.

Approaches to Electrotherapy
Given the natural energy systems of the living cell, there are two approaches
to the application of electrotherapy modalities.
Firstly, one can deliver sufficient energy to overcome the energy of the
membrane and thereby force it to change behavior.
Secondly, one can deliver much smaller energy levels, and instead of forcing
the membrane to change behavior, it can be tickled.
Low energy membrane tickling produces membrane excitement, and
membrane excitement in turn produces cellular excitement.
Excited cells do the same job as bored cells, but they do so at a rather harder
and faster rate. It is the excited cells which do the work rather than the
modality itself.
There has been a general trend over the last few years, for the energy levels
applied in electrotherapy to be reduced.
Ultrasound treatment doses are significantly lower (in terms of US intensity &
pulse ratios) than previously thought to be effective.
Pulsed Shortwave employs power levels which are several orders of
magnitude lower than those applied during continuous shortwave therapy.
The over-riding principle of these interventions is that the application of a low
power/energy modality can enhance the natural ability of the body to
stimulate, direct and control the healing& reparative processes.
Instead of 'hitting the cells' with high energy levels, and thereby forcing them
to respond, the low energy applications are aiming to tickle the cells, to
stimulate them into some higher activity level and thus use the natural
resources of the body to do the work.
One final area of interest is to potentially take the applied energy to really low
levels (microcurrent type therapies) and deliver a current to the tissues that is
remarkably similar to the endogenous currents that appear to be
physiologically effective.
Summary
Electrotherapy has a place within clinical practice. When used appropriately, the
evidence supports its effectiveness. When used in other ways, it is not surprising that
it has little or no beneficial effect. Modality and dose selection appear to be key, and
critical clinical decision making issues.

Ultrasound

Therapeutic ultrasound is one of the more established and most widely used of the
electrophysical agents.
The energy output of the machine is a sound wave which is a mechanical wave
form and in the case of therapeutic ultrasound, it is most often applied with
frequencies between 1 and 3 MHz.
The ultrasound treatment head is the source of this energy, and the ultrasound
machine as such provides the necessary circuitry to generate the sound energy.
Not all tissues will absorb US equally, and thus the effectiveness of the
modality will be influenced by the type of tissue being treated.
The listed sets of effects of ultrasound are best achieved in the tissues that do
absorb the energy most efficiently.
These are the dense collagenous tissues such as ligament, tendon, fascia,
capsule and scar tissue.
Clearly ultrasound can have an effect in other types of tissue (e.g. muscle), but
it would be less effective if used to treat an acute muscle tear than it would be
if used to treat an acute ligament tear the nature of the tissue is a critical
element in the clinical decision making process.

Ultrasound Modes

Ultrasound can be used in THERMAL or NON THERMAL modes.

In thermal mode, it will be most effective in heating the dense collagenous tissues
and will require a higher intensity, preferably in continuous mode to achieve this
effect.
In the non thermal application, lower energy levels, preferably in pulsed mode are
applied in order to achieve cell up regulation without heating.
The primary non thermal effects involve enhancement of the tissue repair process
by optimising the normal inflammatory, proliferative and remodelling events.
Leonard et al (2004) provide evidence that the deep tissue temperature changes
achieved with therapeutic ultrasound are or limited therapeutic value.
Comparative studies on the thermal effects of ultrasound have been reported by
several authors (e.g. Draper et al 1993, 1995a,b,c, Meakins and Watson 2006)
with some interesting, and potentially useful results. Finally, Merrick et al (2003)
demonstrated that different ultrasound machines delivering apparently the same
treatment energy give rise to different amounts of tissue heating and therefore
the effect may be more than simply a dose dependent issue.

Influence of Ultrasound in Soft Tissue Healing

The effect of US during the repair process varies according to the primary events
that are occurring in the tissues.
During the inflammatory phase, US have a stimulating effect on the mast cells,
platelets, white cells with phagocytic roles and the macrophages.
For example, the application of ultrasound induces the degranulation of mast
cells, causing the release of arachidonic acid which itself is a precursor for the
synthesis of prostaglandins and leukotreine which act as inflammatory
mediators.

By increasing the activity of these cells, the overall influence of therapeutic US

are certainly pro-inflammatory rather than anti-inflammatory.
The benefit of this mode of action is not to increase the inflammatory response
as such (though if applied with too greater intensity at this stage, it is a possible
outcome, but rather to act as an inflammatory opimiser.
The inflammatory response is essential to the effective repair of tissue, and the
more efficiently the process can complete, the more effectively the tissue can
progress to the next phase (proliferation).

Enhancement of the inflammatory phase of repair in order to facilitate tissue repair

Studies which have tried to demonstrate the anti inflammatory effect of

ultrasound have failed to do so (e.g.Hashish 1986, 1988), and have suggested that

US is ineffective. It is effective at promoting the normality of the inflammatory

events, and as such has a therapeutic value in promoting the overall repair events
(ter Haar 99).
Employed at an appropriate treatment dose, with optimal treatment parameters
(intensity, pulsing and time), the benefit of US is to make as efficient as possible
to earliest repair phase, and thus have a promotional effect on the whole healing
cascade.
For tissues in which there is an inflammatory reaction, but in which there is no
repair to be achieved, the benefit of ultrasound is to promote the normal
resolution of the inflammatory events, and hence resolve the problem This will
of course be most effectively achieved in the tissues that preferentially absorb
ultrasound i.e. the dense collagenous tissues.
During the proliferative phase (scar production) US also has a stimulative effect
(cellular up regulation), though the primary active targets are now the fibroblasts,
endothelial cells and myofibroblasts.
These are all cells that are normally active during scar production and US is
therefore pro-proliferative in the same way that it is pro-inflammatory it does
not change the normal events, but maximises their efficiency producing the
required scar tissue in an optimal fashion.
Harvey et al (1975) demonstrated that low dose pulsed ultrasound increases
protein synthesis and several research groups have demonstrated enhanced
fibroplasia and collagen synthesis Recent and growing evidence suggests that
there are further effects of US in this area, with a particular emphasis on the
angiogenic effects.
The application of therapeutic ultrasound can influence the remodelling of the
scar tissue in that it appears to be capable of enhancing the appropriate orientation
of the newly formed collagen fibres and also to the collagen profile change from
mainly Type III to a more dominant Type I construction, thus increasing tensile
strength and enhancing scar mobility.
Ultrasound applied to tissues enhances the functional capacity of the scar tissues.
The role of ultrasound in this phase may also have the capacity to influence
collagen fibre orientation.
Recent papers have identified the potential role for therapeutic ultrasound in
relation to their capacity to influence various cytokines and mediators of the
repair process. For example, ultrasound has a capacity to influence the production
of TGF- (Mukai et al 2005).
The application of ultrasound during the inflammatory, proliferative and repair
phases is not of value because it changes the normal sequence of events, but
because it has the capacity to stimulate or enhance these normal events and thus
increase the efficiency of the repair phases.
It would appear that if a tissue is repairing in a compromised or inhibited fashion,
the application of therapeutic ultrasound at an appropriate dose will enhance this
activity.
If the tissue is healing normally, the application will, it would appear, speed the
process and thus enable the tissue to reach its endpoint faster than would
otherwise be the case. The effective application of ultrasound to achieve these
aims is dose dependent.

Combination Therapy

In general terms, combination therapy involves the simultaneous application

of ultrasound (US) with an electrical stimulation therapy.
In Europe, Diadynamic Currents are frequently utilised, but in the UK, US is
most often combined with bipolar Interferential Therapy (IF).
There is a significant lack of published material in this area. And much of the
information herein is anecdotal or based on the experience of those who use
the modality frequently.
Broadly, the effects of the combined treatment are those of the individual
modalities. There is no evidence at present for any additional effects which
can only be achieved when the modalities are used in this particular way.

It is suggested that:
By combining US with IF, the advantages/effects of each treatment modality
can be realised, but lower intensities are used to achieve the effect.
the accommodation effects that accompany IF treatment are reduced (or even
eliminated)
The main advantages on such a combination are said to be:
in localizing lesions (especially chronic) i.e. diagnostic use
in ensuring accurate localisation of US treatment - to provide increased
accuracy/effectiveness in treating deeper lesions.
in treating trigger points
Possible Explanation:
Exposure of a peripheral nerve to US reduces the membrane resting potential
by increasing its permeability to various ions (especially Sodium (Na+ ) and
Calcium (Ca ++ ).
By virtue of this adjusted permeability, the nerve membrane is taken closer to
its threshold (the point where it depolarizes), though doesnt usually make the
nerve fire.
The simultaneous application of the Interferential current through the nerve
induces the depolarisation potential, though it will take a smaller current than
usual to achieve this due to the potentiation effect of the ultrasound.
This can easily be demonstrated. If both the US and IF are applied, and during
the application, the US is turned down to zero, the sensation produced by the
IF will diminish even though the IF <- 70 mV
Increased sodium ion permeability
Intensity has not been changed. The intensity of the IF sensation returns when
the US is turned up again.
The combination of US with IF appears to give rise to less adverse treatment
effects than are associated with the combination of US with Diadynamic
Currents, or other electrical stimulations.
It has also been suggested that a greater effective treatment depth can be
achieved with the US - IF combination though there is no direct evidence for
such a claim.

In summary, it would appear that by combining the two treatment modalities,

none of the individual effects of the treatments are lost, but the benefit is that
lower treatment intensities can be used to achieve the same results, & there are
additional potential benefits in terms of diagnosis & treatment times.

TREATMENT NOTES:
A) Diagnostic Use of Combined Therapy
It is suggested that a continuous US output of 0.5W/cm should be used for this
procedure, though numerous practitioners do claim to have achieved
significant results with lower intensities.
A frequency of 1MHz is preferable if available as it gives more effective
penetration into the tissues. The IFT output is most commonly set to 100Hz
(with no sweep) using a bipolar output.
Technique:
Place the indifferent electrode (the normal IFT pad electrode) in a position so
that the current can pass through the tissue in question.
As a general guide, it can be placed on the same aspect of the limb (more
usual for superficial lesions) or on the opposite side of the limb (for deeper
lesions).
Turn on the US first, followed by the IFT (parameters as above).
Starting with the US head distant from the lesion, gradually increase the IFT
output intensity until the `normal' tingling is encountered by the patient.
Move towards the lesion site, noting any areas of increased sensitivity, local or
referred pain.
The point of maximal sensitivity is assumed to be the focal point of the lesion,
though it will not provide information as to the precise tissue in question, nor
to depth only a geographical location.
This position is usually consistent and reproducible.
B) Treatment with Combined Therapy
Diagnostic and therapeutic uses of Combination Therapy need not be used
together.
As a treatment, it is appropriate when the therapeutic effects of US and those
of IFT are both justified.
At the present time and in the absence of any specific evidence of additional
effect when used in combination, this would seem to be the sole justification
for the modality.
The individual doses for the US and IFT should be those which are
appropriate for the lesion and the required effects.
There is no evidence that special treatment doses are required. It should be
noted however; that the intensity of the IF required achieving the usual effect
is likely to be lower than normal.
Some manufacturers suggest that it is not necessary to incorporate a swing in
the IF dose as the effect of accommodation is minimized.
There does not appear to be any reason why an appropriate frequency swing
should not be used if it is appropriate to the effect required.

If the treatment times are dissimilar, there is a potential problem in that the US
component will usually finish first, leaving the IFT element to continue in
isolation.
When the required treatment times are similar, the combination of the
modalities can save time and effort (even without additional effect). When
they are dissimilar, it may be as effective to apply two separate treatments.
It is important to observe the safe & effective US treatment technique during
combined treatment i.e. always using a moving treatment head, maintain
effective contact, & maintain the perpendicular relationship between the
treatment head & the patients skin whenever possible.

Treatment Example:
Patient with an acute lesion/ tear of the lateral ligament of the ankle.
Ultrasound is justified on the basis that it will promote the inflammatory/repair
process and interferential is used for its effect in reducing acute pain.
US dose (based on normal dose calculations) 3MHz, 0.2 W/cm2, Pulse 1:4, 10
minutes Interferential dose (for acute pain) 90 130Hz, bipolar, 10 minutes.
Interferential pad electrode placed medially at the ankle, US treatment head
applied over the torn component(s) of the lateral ligament.
The treatment could be more effective than either one modality in isolation,
though there is no evidence that by using them simultaneously, there is any
advantage over using them sequentially.
Contraindications:
There do not appear to be any specific contraindications for combination
therapy other than those for the individual modalities.