Electrical Stimulation Flashcards
1
Q
Electrical Stimulation (e-stim) =
A
uses electrical currents to produce a physiological response in the tissues
2
Q
Indications:
A
Pain management, muscle strengthening, wound healing, edema reduction, etc.
3
Q
Contraindications:
A
Pacemakers, pregnancy (over the abdomen or pelvis), active infection, malignancy, and areas with poor sensation.
4
Q
Muscle Re-education:
A
Use neuromuscular electrical stimulation (NMES) for muscle strengthening and re-education in cases like muscle weakness following injury or surgery.
5
Q
Pain Management:
A
For acute or chronic pain, options like TENS (Transcutaneous Electrical Nerve Stimulation) can be used to modulate pain perception.
6
Q
Edema Control:
A
Interferential current (IFC) or high-voltage pulsed current (HVPC) can be used to reduce swelling and promote lymphatic drainage.
7
Q
Post-Injury or Surgery:
A
It can aid in muscle strengthening (via NMES), pain reduction (via TENS), or improving circulation to accelerate healing.
8
Q
Active Recovery:
A
E-stim can be integrated into rehabilitation exercises by stimulating muscles while the patient performs active movement.
9
Q
Functional Re-education:
A
In patients with neurological conditions, e-stim can help in restoring functional movement by encouraging neuromuscular re-education.
10
Q
The key is incorporating e-stim in conjunction with ___ to encourage ___
A
movement
functional recovery
11
Q
Electrical stimulation affects pain perception through several mechanisms:
A
Gate Control Theory (TENS)
Endorphin Release: Low-frequency TENS
Increased Blood Flow
Muscle Contraction
12
Q
Gate Control Theory (TENS):
A
High-frequency stimulation can activate A-beta fibers (large, myelinated fibers) to “close the gate” in the spinal cord, preventing pain signals from reaching the brain
13
Q
Endorphin Release: Low-frequency TENS:
A
an stimulate the release of endorphins, the body’s natural painkillers, leading to pain relief
14
Q
Increased Blood Flow:
A
Electrical currents can promote vasodilation, which can help reduce inflammation and relieve pain
15
Q
Muscle Contraction:
A
E-stim (e.g., NMES) can also promote muscle contraction, potentially relieving muscle spasm and discomfort associated with pain
16
Q
When Are Passive Physical Agents Necessary?
A
Acute Pain and Inflammation
Muscle Spasm/Spasticity
Facilitation of Movement
Chronic Pain Management
Wound Healing or Edema Reduction
17
Q
Acute Pain and Inflammation =
A
Indication: In cases of acute pain (like after an injury or surgery), passive modalities like ice or electrical stimulation (TENS) can be used to manage pain and reduce swelling.
This enables the patient to tolerate physical therapy or active exercises that they may not be able to participate in otherwise due to pain or discomfort.
Goal: To manage pain and make it possible for the patient to engage in more active movements, strength training, and functional rehabilitation exercises without being hindered by severe discomfort.
18
Q
Muscle Spasm/Spasticity =
A
Indication: When there is muscle spasm or spasticity, using modalities like heat, electrical stimulation (NMES), or ultrasound can help reduce muscle tension, relax tight muscles, and improve circulation.
This, in turn, allows patients to engage in physical therapy and range of motion exercises.
Goal: To reduce the muscle spasm so that the patient can more effectively work on mobility, stretching, and strengthening exercises.
19
Q
Facilitation of Movement =
A
Indication: For individuals with neurological impairments or weakness (like in cases of stroke, spinal cord injury, or Parkinson’s disease), neuromuscular electrical stimulation (NMES) can be used to promote muscle contraction and improve strength.
This may make it easier for the patient to perform functional movements and participate in therapeutic exercises.
Goal: To facilitate motor control and increase strength to enable patients to engage in active exercises.
20
Q
Chronic Pain Management =
A
Indication: In cases of chronic pain, such as in conditions like osteoarthritis, fibromyalgia, or chronic back pain, modalities like TENS or interferential current (IFC) can help modulate pain and reduce the need for pain medications.
By controlling pain, patients can more effectively engage in an active rehabilitation program.
Goal: To decrease pain levels enough to allow for participation in strengthening, functional movement, or rehabilitation activities.
21
Q
Wound Healing or Edema Reduction =
A
Indication: Electrical stimulation (HVPC) and shortwave diathermy (SWD) can be used in wound healing or to reduce edema, especially in cases of post-surgical recovery or trauma.
These modalities can improve tissue perfusion, reduce swelling, and promote healing, making it easier for patients to participate in rehabilitation and functional exercises.
Goal: To improve tissue healing and edema control, facilitating movement and functional recovery.
22
Q
Reasons you may use to facilitate active treatment:
A
- Pain
- Edema
- Loss of function
- ROM
- Tissue Healing (of skin)
- Augmentation of blood flow
23
Q
Contraindications
A
Cardiac Arrhythmia
Pacemakers
Pregnancy
Cancer
Open Wounds (Except When Treating the Wound)
Exposed Hardware
Carotid Sinus
Epilepsy
Across the Spine
24
Q
Precautions (where extra caution should be taken):
A
Menstruation
Cancer
Across the Spine
25
Menstruation:
While generally not contraindicated, electrical stimulation near the pelvic region during menstruation can be uncomfortable for some patients.
It's also considered a precaution due to potential interactions with hormonal fluctuations, which could alter how the body responds to the modality.
26
Cancer:
While cancer itself is a contraindication for certain modalities, if used cautiously, electrical stimulation may sometimes be employed to manage pain or wound healing in some cancer patients, as long as it is not over malignant tissue.
Always check with the oncologist before applying.
27
Across the Spine:
While generally not contraindicated, special care should be taken when applying modalities across the spine.
Avoid using high-intensity settings or electrical stimulation directly over the spinal cord in certain conditions, especially for patients with spinal cord injuries, implants, or pacemakers.
28
Best Available Evidence / Totality of Evidence:
Systematic Reviews (the gold standard of evidence)
Randomized Controlled Trials (RCTs)
Cohort Studies and Case-Control Studies
Expert Consensus and Clinical Guidelines
29
Clinical Expertise / Synthesis of Evidence:
Patient’s response to previous treatments
Comorbidities (e.g., diabetes affecting wound healing)
The nature of the injury
The timing of treatment
30
Patient Values / Circumstances:
Patient’s values (what are their goals? Do they prioritize pain reduction or improving mobility?)
Patient's preferences (are they comfortable with certain interventions or therapies?)
Cultural and social factors (what resources are available to them, and how might their circumstances affect treatment choices?)
31
EBM = A Balanced Approach
Best Available Evidence helps ensure that decisions are grounded in science.
Clinical Expertise ensures that decisions are tailored to the patient and are pragmatically applied.
Patient Values ensure the treatment plan is individualized, respectful of the patient’s needs, and ethical.
32
Knee Pain and Mobility Impairments: Meniscal and Articular Cartilage Lesions
Finding:
Clinicians should incorporate neuromuscular stimulation/re-education for patients following meniscus procedures to improve:
> Quadriceps strength
> Functional performance
> Knee function
B (Moderate Evidence):
Supported by at least one high-quality randomized controlled trial or a preponderance of level II studies.
33
Knee Stability and Movement Coordination Impairments: Knee Ligament Sprain (Revision 2017 - APTA)
Finding:
Neuromuscular electrical stimulation (NMES) should be used for 6 to 8 weeks to complement muscle strengthening exercises in patients recovering from ACL reconstruction, with the goal of:
> Enhancing quadriceps muscle strength
> Improving short-term functional outcomes
A (Strong Evidence):
Supported by a preponderance of level I and/or level II studies, including at least one level I study.
34
Neuromuscular stimulation (NMES) plays a crucial role in:
muscle strengthening and functional recovery for patients recovering from meniscal procedures and ACL reconstruction
35
Carpal Tunnel Syndrome (CTS)
Interferential Current (IFC) for Short-Term Pain Relief
Finding:
Clinicians may offer a trial of interferential current (IFC) for short-term pain symptom relief in adults with idiopathic, mild to moderate CTS (without pacemakers).
C (Weak Evidence):
Supported by one level II study or a preponderance of level III and IV studies, including consensus statements from content experts.
36
Carpal Tunnel Syndrome (CTS)
Iontophoresis for Mild to Moderate CTS
Finding:
Clinicians should NOT use iontophoresis for the management of mild to moderate CTS.
Supported by one high-quality randomized controlled trial or a preponderance of level II studies.
37
Midportion Achilles Tendinopathy (2024 Revision)
Finding:
No recommendation has been made for the use of electrical modalities for Midportion Achilles Tendinopathy.
N/A
For Achilles Tendinopathy, there is no specific recommendation for electrical modalities in the most recent CPG (2024).
38
Interferential current (IFC) may provide ___ pain relief for mild to moderate CTS with ___ evidence supporting this treatment.
short-term
weak
39
___ is NOT recommended for mild to moderate CTS, supported by moderate evidence showing it is not beneficial for these conditions.
Iontophoresis
40
Heel Pain – Plantar Fasciitis (2023 Revision)
Primary Treatment Recommendations:
Manual therapy, stretching, and foot orthoses are recommended instead of electrotherapeutic modalities to achieve short-term and long-term improvements in clinical outcomes for individuals with heel pain/plantar fasciitis.
41
Heel Pain – Plantar Fasciitis (2023 Revision)
Second-Line Treatment Options:
Iontophoresis or premodulated interferential current (IFC) electrical stimulation may be considered as second-line treatment.
D (Conflicting Evidence):
Higher-quality studies on this topic show disagreement in conclusions, leading to this recommendation being based on conflicting studies.
42
Hip Pain and Movement Dysfunction Associated with Nonarthritic Hip Joint Pain
Finding:
No recommendation has been made for the use of electrical modalities in the management of nonarthritic hip joint pain.
N/A (Not Applicable):
No recommendation was provided, as no relevant evidence or consensus was presented in the guideline for electrical modalities.
43
CPG: Lateral Elbow Pain and Muscle Function Impairments (APTA)
1. Use of TENS for Short-Term Pain Relief
Finding:
Clinicians may use burst TENS applied to the painful region or high- or low-frequency TENS applied to acupuncture points for short-term pain relief in individuals with lateral epicondylitis (LET).
C (Weak Evidence)
This recommendation is based on a single level II study or a preponderance of level III and IV studies, including consensus statements by content experts.
44
CPG: Lateral Elbow Pain and Muscle Function Impairments (APTA)
2. Use of Iontophoresis for Anti-Inflammatory Drug Delivery
Clinicians may use iontophoresis with an anti-inflammatory drug early in the rehabilitation phase (no later than 2-4 weeks from onset or aggravation of symptoms) for individuals with highly irritable symptoms of LET.
C (Weak Evidence)
This recommendation is based on a single level II study or a preponderance of level III and IV studies, including consensus statements by content experts.
45
TENS for LET:
Burst TENS or high/low-frequency TENS applied to acupuncture points may be used for short-term pain relief.
However, the evidence is weak (Level C), based on lower-level studies and expert consensus.
46
Iontophoresis with Anti-Inflammatory Drugs:
Iontophoresis may be used early in rehabilitation (within 2-4 weeks) for highly irritable LET symptoms, again with weak evidence (Level C) supporting its use.
47
CPG: Hamstring Strain Injury in
Athletes (APTA)
Finding:
No Recommendation
48
CPG: Lateral Ankle Ligament Sprains Revision (APTA)
Finding:
There is moderate evidence both for and against the use of electrotherapy for the management of acute ankle sprains.
D (Conflicting Evidence)
Higher-quality studies conducted on this topic disagree with respect to their conclusions. The recommendation is based on these conflicting studies.
49
CPG: Interventions for the Management
of Acute and Chronic Low Back
Pain: Revision 2021 (APTA)
Finding:
No Recommendation
50
CPG: Nonarthritic Hip Joint Pain (APTA)
Finding:
No Recommendation
51
CPG: Physical Therapy Management of Older Adults With Hip Fracture (APTA)
Finding: strength
Physical therapists may use electrical stimulation for quadriceps strengthening if other approaches have not been effective.
Level of Evidence: C (Weak Evidence)
A single level II study or a preponderance of level III and IV studies, including statements of consensus by content experts, support the recommendation.
52
CPG: Physical Therapy Management of Older Adults With Hip Fracture (APTA)
Finding: pain
Physical therapists may use electrical stimulation for pain if it is not sufficiently managed with usual strategies.
Level of Evidence: C (Weak Evidence)
A single level II study or a preponderance of level III and IV studies, including statements of consensus by content experts, support the recommendation.
53
Electrical Stimulation for Quadriceps Strengthening:
Electrical stimulation may be considered as an adjunct if conventional methods are not sufficient for strengthening the quadriceps after a hip fracture. However, the evidence supporting its effectiveness is weak.
54
Electrical Stimulation for Pain Management:
Similarly, electrical stimulation can be used for pain relief when other methods have not been effective, with weak evidence backing its use.
55
CPG: Distal Radius Fracture Rehabilitation (APTA)
Finding:
There was only 1 trial (level II) on electrotherapy (TENS) treatment, which indicated that a 15-minute TENS treatment may result in transient postoperative pain reduction.
However, this pain reduction could not be maintained for 24 hours and was not significantly different from pain reduction induced by a placebo effect.
The evidence from this study was insufficient to support a recommendation for TENS application.
Level of Evidence: N/A
56
CPG: Patellofemoral Pain (APTA)
Finding:
Clinicians should NOT use biophysical agents, including:
Ultrasound
Cryotherapy
Phonophoresis
Iontophoresis
Electrical stimulation
Therapeutic laser
Level of Evidence: B (Moderate Evidence)
A single high-quality randomized controlled trial or a preponderance of level II studies support the recommendation.
57
CPG: Knee Pain and Mobility Impairments: Meniscal and Articular Cartilage Lesions Revision 2018 (APTA)
Finding:
Clinicians should provide neuromuscular stimulation/re-education to patients following meniscus procedures to:
> Increase quadriceps strength
> Improve functional performance
> Enhance knee function
Level of Evidence: B (Moderate Evidence)
A single high-quality randomized controlled trial or a preponderance of level II studies supports the recommendation.
58
CPG: Knee Stability and Movement Coordination Impairments: Knee Ligament Sprain Revision 2017 (APTA)
Finding:
Neuromuscular electrical stimulation (NMES) should be used for 6 to 8 weeks to augment muscle strengthening exercises in patients after ACL reconstruction to:
> Increase quadriceps muscle strength
> Enhance short-term functional outcomes
Level of Evidence: A (Strong Evidence)
A preponderance of level I and/or level II studies supports the recommendation. This includes at least one level I study.
59
CPG: Shoulder Pain and Mobility Deficits: Adhesive Capsulitis (APTA)
Finding:
Clinicians may utilize shortwave diathermy, ultrasound, or electrical stimulation combined with mobility and stretching exercises to:
> Reduce pain
> Improve shoulder range of motion (ROM) in patients with adhesive capsulitis.
Level of Evidence: C (Weak Evidence)
A single level II study or a preponderance of level III and IV studies, including statements of consensus by content experts, support the recommendation.
60
CPG: Chronic Pain (Primary and Secondary) in Over 16s: Assessment and Management of Chronic Primary Pain (NICE)
Finding:
Do not offer any of the following to people aged 16 years and over to manage chronic primary pain because there is no evidence of benefit:
TENS
Ultrasound
Interferential therapy
61
CPG: Low Back Pain and Sciatica in Over 16s: Assessment and Management (NICE)
Finding:
Do not offer percutaneous electrical nerve stimulation (PENS) for managing low back pain with or without sciatica.
Do not offer transcutaneous electrical nerve stimulation (TENS) for managing low back pain with or without sciatica.
Do not offer interferential therapy for managing low back pain with or without sciatica.
62
For low back pain and sciatica in individuals over 16, ___, ___, and ___ are not recommended due to lack of proven benefit.
PENS
TENS
interferential therapy
63
American College of Rheumatology/ Arthrosi Foundation Guidline for Management of OA of the Hand, Hip, and Knee
recommend against:
iontophoresis - conditionally recommended against hand (first carpometacarpal)
pulsed vibration therapy - conditionally recommended against knee
transcutaneous electrical nerve stimulation - strongly recommended against knee and hip
64
effects of high-volt pulsed current electrical stimulation on delayed-onset muscle soreness
HVPC as we studied it was ineffective in providing lasting pain reduction and at reducing ROM and strength losses associated with DOMS
can provide short-term relief from pain associated with DOMS, it does not appear effective in providing long-lasting pain reduction, improving range of motion, or preventing strength loss typically associated with DOMS
Other interventions like active recovery, stretching, foam rolling, or ice/heat therapy might provide more meaningful benefits for muscle recovery post-exercise
65
Effectiveness of interferential current in patients with chronic non-specific low back pain: a systematic review with meta-analysis
moderate-quality evidence shows that IC is probably better than placebo for reducing pain intensity and disability immediately post-treatment in patients with chronic non-specific LBP
may be useful as part of a comprehensive treatment plan for managing chronic LBP, alongside other modalities and active rehabilitation strategies
66
systematic review to inform a world health organization (WHO) CPG: benefits and harms of TENS for chronic primary low back pain in adults
based on very low certainty evidence, TENS resulted in brief and marginal reductions in pain (not deemed clinically important) and a short-term reduction in pain catastrophizing in adults with CPLBP, while little to no differences were found for other outcomes
TENS should not be considered a first-line treatment and may only be used as a supplementary approach
67
TENS for chronic neck pain
very low-certainty evidence of a difference between TENS compared to sham TENS on reducing neck pain
unsure about the effect estimate
present: insufficient evidence regarding the use of TENS in patients with neck pain
TENS should not be considered a mainstay treatment for chronic neck pain, and its use should be carefully evaluated in clinical practice
68
TENS for chronic pain
methodological quality of reviews was good
quality of evidence w/in them was very low
unable to conclude with any confidence that, in people with chronic pain, TENS is harmful, or beneficial for pain control, disability, health-related quality of life, use of pain relieving medicines, or global impression of change
69
TENS for acute pain
TENS reduces pain intensity over and above that seen with placebo (no current) when administered as a stand-alone treatment for acute pain in adults
high risk of bias associated with inadequate sample sizes in treatment arms and unsuccessful blinding of treatment interventions makes definitive conclusions impossible
70
TENS for neuropathic pain in adults
very low quality evidence
71
TENS for pain control in women with primary dysmenorrhoea
may reduce pain compared with placebo or no treatment
future RCTs should focus more on secondary outcomes of this reviwe
72
Key Aspects of Enhanced Therapeutic Alliance:
Patient-Centered Questions
Active Listening
Empathy and Validation
73
types of currents
direct
alternating
pulsed
74
direct current =
type:
- conventional
- reversed
- reverse-interrupted
parameters:
- polarity
- intensity
75
alternating current =
symmetrical
asymmetrical
- balanced
- unbalanced
symmetrical and balanced parameters:
- frequency
- intensity
unbalanced parameters:
- polarity
- frequency
- intensity
76
pulsed current =
monophasic
biphasic
- symmetrical
- asymmetrical
monophasic parameters:
- polarity
- frequency
- pulse duration
- intensity
- ramps
symmetrical parameters:
- intensity
- frequency
- pulse duration
- ramps
- on-off times
asymmetrical parameters:
- polarity
- intensity
- frequency
- pulse duration
- ramps
- on-off times
77
You will modulate three things
primarily:
Frequency
Phase duration
Amplitude/Intensity
78
Short, fat wave =
(lower frequency, higher amplitude, longer duration)
= Likely to provide deep stimulation with stronger muscle contractions and longer-lasting pain relief, suitable for muscle strengthening.
79
Tall, skinny wave =
(higher frequency, shorter amplitude, shorter duration)
= Likely to provide sensory stimulation for pain management with less muscular contraction, good for pain relief through endorphin release.
80
Something in between =
A balanced approach, providing both muscle contraction and pain relief, depending on your treatment goals.
81
Strength Duration Curve Theory
Key Elements
Phase Duration (Strength): length of time that each pulse lasts, measured in microseconds (µs). It indicates how long the electrical pulse is applied to the tissue
Amplitude (Intensity): Amplitude or intensity refers to the strength of the electrical current, typically measured in milliamps (mA) or volts (V).
82
Shorter phase durations =
(around 50-150 µs) activate sensory nerves without significantly stimulating motor nerves or muscle fibers.
83
Longer phase durations =
(200-500 µs) can effectively stimulate motor neurons, leading to stronger muscle contractions.
84
A higher amplitude provides =
a stronger stimulus, which can recruit more motor units (muscle fibers).
85
A lower amplitude =
may only stimulate sensory nerves and can be used for pain management or to elicit a mild response.
86
The Theory Behind the Strength-Duration Curve:
the longer the phase duration, the less amplitude (intensity) is required to activate motor neurons for a given muscle contraction
At very short durations (e.g., 10 µs), high amplitude (intensity) is needed to recruit motor units. This is often used for pain modulation (sensory stimulation) because it affects the sensory fibers more than motor fibers.
At longer durations (e.g., 200-500 µs), lower amplitude is sufficient to activate motor fibers, which is useful for muscle strengthening or rehabilitation.
87
nerve fibers
A - alpha
A - beta
A - delta
C
88
A - alpha fibers
size - large
myelination - high
diameter - 12-20 um
conduction velocity - 70-120 m/s
receptor - proprioceptive mechanoreceptor
89
A - beta fibers
size - med
myelination - high
diameter - 6-12 um
conduction velocity - 36-72 m/s
receptor - proprioceptive mechanoreceptor
90
A - delta fibers
size - smaller
myelination - less
diameter - 1-4 um
conduction velocity - 5-15 m/s
receptor - pain, crude touch, pressure, temperature
91
C fibers
size - smallest
myelination - un-myelinated
diameter - 0.1-1 um
conduction velocity - 0.2 - 2 m/s
receptor - pain, pressure, touch, SLOW
92
For Pain Management:
TENS and other electrical stimulation modalities generally aim to stimulate Aβ and Aδ fibers for pain modulation.
C fibers are typically targeted in cases of chronic pain using longer pulse durations to alleviate discomfort.
93
For Muscle Contraction:
Aα fibers are crucial for muscle contraction. Neuromuscular electrical stimulation (NMES) targets these fibers for muscle reeducation and strengthening.
94
For Sensory Stimulation:
Aβ fibers are responsible for sensations like touch, which can be modulated for pain relief or sensory feedback in therapeutic settings.
95
Gate Theory (Melzack & Wall)
A Beta (Large, Fast, Sensory)
A delta, C (Smaller, Slower)
non-painful stimuli (like touch or vibration) can "close the gate" in the spinal cord, preventing pain signals from reaching the brain, which is why stimulating certain sensory fibers can reduce the perception of pain
"Pain can be reduced by stimulating non-painful sensory pathways, essentially 'closing the gate' to pain signals in the spinal cord."
96
Gate Theory Application:
* Target nerve: A Beta
* Frequency: 80-150 Hz
* Phase Duration: 50-100 µs
* Intensity: Strong, sub motor tingle
* Pain relief: Gate theory
* Duration of effect: As long as current is on
97
Motor Level Pain Mod Applied
Beta-Endorphin release
aims to stimulate the A-delta fibers and alpha motor neurons to induce a physiological response that leads to the release of endorphins
Target nerve: A Delta fibers
Frequency: 1-10 Hz
Phase Duration: >150 µs
Intensity: Strong, visible contractions
Pain relief: Beta endorphins
Duration of effect: Possibly hours
98
gate theory approach is often used in TENS units to manage:
acute pain, providing immediate relief while the treatment is ongoing.
99
motor level pain mod approach is often used in TENS units to manage:
chronic pain conditions
100
Descending Pain Modulation
Hyperstimulation Analgesia or Noxious Level Pain Mod
helps modulate pain through the central nervous system, leading to pain relief that is mediated by various chemicals like serotonin, beta-endorphins, and dynorphins
Target nerve: C Fibers
Frequency: 100-150 Hz OR 2-7 pps
Phase Duration: >1 millisecond
Intensity: As high as tolerable (PAIN!)
Pain relief: Descending serotonergic pathway, Beta-endorphins, Dynorphins
Duration of effect: Several hours
101
descending pain modulation is often used in high-intensity TENS (noxious TENS) settings or electrotherapy for individuals with:
chronic pain or acute injuries requiring a more aggressive pain management approach.
102
Iontophoresis
process in which ions are
transferred through intact skin via electrical potential
administer aqueous solutions of FDA approved medications prescribed by physician
used as alternative to injections
Precautions: Skin irritation
(erythema, pruritis, increased temperature), burns (especially at cathode)
Residual skin break down (long term treatments)
103
Drugs used with Iontophoresis
dexamethasone = inflammation
lidocaine = soft tissue pain
salicytates - muscle and joint
104
Iontophoresis * Treatment dosage
increased 10mA/min per day up to max of 80
Patient must be educated on potential skin breakdown
Clinician must be aware of other meds currently being taken
