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ELECTRICAL STIMULATION DEVICES pages 73 - 117 DR. GRANT CLASSIFICATION Electrical stimulation devices can be classified in several ways. One method is based on the type of current that is used (AC or DC) Secondly, the amount of voltage that may be produced (Low voltage or High voltage) Thirdly, by reference to some unique aspect of the current that is used (IF, Russian Stim.) INTRODUCTION TO ELECTROTHERAPY Electrotherapy - in particular interferential therapy - has proven to be one of the more successful therapies. Such popularity is for good reason. Practitioners using electrotherapy devices have experienced favorable results in relieving pain. 3 INTRODUCTION TO ELECTROTHERAPY The degree of success achieved in adding electrotherapy to a practice is measured in terms of how quickly and efficiently it can be learned and implemented. Electrotherapy devices are now “user friendly” 4 INTRODUCTION TO ELECTROTHERAPY Interferential quadrapolar, premodulated quadrapolar premodulated (bipolar), and Russian and biphasic stimulation , conveniently and economically can be housed in one easy-to -use unit. 5 INTERFERENTIAL THERAPY The name Interferential therapy stems from the concept of two currents interfering with each other This becomes readily apparent when one views the four electrodes (quadrapolar) that are necessary to produce the standard interferential effect in a patient 6 INTERFERENTIAL THERAPY I.F. is one of a number of electrical stimulation techniques used in modern physiotherapy. The common feature of all modalities is the ability to facilitate healing in damaged tissues However, I.F. has a number of advantages: comfortable and penetrates deeper 7 INTERFERENTIAL THERAPY The beat frequency in Hz is simply the difference in frequency between the two medium frequency currents. This “beating” is the actual “interferential effect” The beat frequency relates solely to the number of times per second the intensity increases and decreases. 8 INTERFERENTIAL THERAPY PRE-MODULATED BIPOLAR It is possible to deliver I.F. currents to a patient using two, instead of the conventional four electrodes. In this system, the two currents are “mixed” in the machine and delivered to the patient via two electrodes (premodulated). 9 INTERFERENTIAL THERAPY PRE-MODULATED BIPOLAR Premodulated bipolar therapy helps to reduce pain and increase range of motion. In some cases, it provides an effective substitute for quadrapolar treatment especially when treating small areas of the body where four electrodes cannot be placed. 10 INTERFERENTIAL THERAPY PRE-MODULATED BIPOLAR Premodulated bipolar therapy utilizes one output jack, and produces a composite wave form identical to the interferential current, while using only two electrodes. 11 INTERFERENTIAL THERAPY The average treatment time for most applications being 20 to 30 minutes. On the first treatment session, it is wiser to halve this, in order to ensure that there is no abnormal response from the patient. 12 INTERFERENTIAL THERAPY TREATMENT DURATION There has never been a set number of treatment sessions for any particular clinical problem since all patients and problems are different. 13 INTERFERENTIAL THERAPY TREATMENT DURATION However, if the overall treatment program has been carefully designed and delivered , then good results should be expected fairly quickly. 14 INTERFERENTIAL THERAPY TREATMENT DURATION I.F. like other forms of electrotherapy, are meant to be used as an adjunct to other forms of treatment. In most cases, six to ten sessions of I.F., together with other measures should produce considerable improvement in the patient. 15 INTERFERENTIAL THERAPY There is no point in continuing with a technique which appears to be having no effect. If the patient’s condition is unchanged after one or two treatments, then the situation needs re-assessing. 16 INTERFERENTIAL THERAPY Assuming that the machine is working correctly and is applied properly, then poor results should indicate possible change in electrode position and/or a change in frequency/intensity. The physiological effect of I.F. depends on the frequency of the current. 17 INTERFERENTIAL THERAPY PHYSIOLOGICAL OBJECTIVES Pain relief both acute and chronic Reduction of edema re-education and strengthening of muscle. Stimulation and improvement of circulation General facilitation of healing 18 INTERFERENTIAL THERAPY I.F. can and should be combined with other modalities except ice (over the electrodes) and diathermy. Combining treatments implies giving two different but complimentary treatments at different times or in some instances at the same time (moist heat) 19 INTERFERENTIAL THERAPY The generally accepted range of frequency is 0 to 150 Hz, with a low range from 0 to 10 Hz, commonly accepted as the appropriate treatment for increasing local blood circulation; and a high range from 80 to 150 Hz which is used for pain relief. 20 INTERFERENTIAL THERAPY CONTRAINDICATIONS Pacemakers Thrombosis Cardiac Conditions Bacterial Infections Malignancy 21 INTERFERENTIAL THERAPY WARNINGS Pregnancy Implants of any electrical nature Transcerebrally Skin diseases 22 INTERFERENTIAL THERAPY 24 INTERFERENTIAL THERAPY INTERFERENTIAL THERAPY INTERFERENTIAL THERAPY INTERFERENTIAL THERAPY 31 32 33 35 Questions regarding Interferential therapy? RUSSIAN STIMULATION DR. GRANT Pain Alliance Institute RUSSIAN STIMULATION Dr. Y.M. Kots, a Russian physiatrist, has been credited with the development of Russian Stim during the late 1960’s. Presented seminars in the U.S. on the use of EMS to augment strength gain RUSSIAN STIMULATION The stimulators developed in the U.S. and Canada after Dr. Kots presentations were termed Russian current generators. These stimulators deliver a medium frequency (2,000 to 10,000 Hz) The peak current intensity stimulates muscle very well and is comfortable. RUSSIAN STIMULATION They presently deliver a medium frequency, polyphasic AC wave form. The pulse can be varied from 50 to 250 m.sec.; The phase duration will be 1/2 the pulse duration. As the pulse frequency increases, the phase duration decreases. RUSSIAN STIMULATION Because it is a fast oscillating AC current, as soon as the nerve repolarizes it is stimulated again, producing a current that will maximally summate muscle contraction. The frequency (bursts per second) is also a variable that can be controlled. RUSSIAN STIMULATION AC medium frequency 2500 Hz Primary purpose is for muscle rehab/re-education. Also used for reducing muscle spasms RUSSIAN STIMULATION PHYSIOLOGICAL EFFECTS Muscle strengthening and reeducation Decrease edema Increase blood flow Reduces muscle spasm This would make the muscle respond with a twitch rather than a gradually increasing mechanical contraction. RUSSIAN STIMULATION PHYSIOLOGICAL EFFECTS Gradually increasing the number of bursts interrupts the mechanical relaxation cycle of the muscle and causes more shortening to take place . RUSSIAN STIMULATION The initial uses of Russian Stimulation in the U.S. were for rehabilitation following surgical procedures such as ACL repair. Strengthening of the quadriceps muscle to correct atrophy of disuse has become a standard, effective treatment procedure. RUSSIAN STIMULATION INDICATIONS Chronic back pain Post-injury muscle atrophy and/or wasting Post-casting Muscle spasms RUSSIAN STIMULATION CONTRAINDICATIONS Pacemakers Malignant lesions Upper thorax (anterior) Pregnancy RUSSIAN STIMULATION APPLICATION 10/50 pre-set Start with low on times and long off times with long ramp times As strength begins to return, increase on times and decrease off times with shorter ramp RUSSIAN STIMULATION PAD PLACEMENT Bipolar technique Origins and insertions and/or until you see a muscle contraction that is tolerable to the patient. RUSSIAN STIMULATION SUMMARY When an electrical stimulation is applied to muscle or nerve tissue, the result will be tissue membrane depolarization, provided that the current has the appropriate intensity, duration, and waveform to reach the tissue’s excitability threshold. RUSSIAN STIMULATION SUMMARY Muscle contraction will change according to changes in current. As the frequency of the electrical stimulus increases, the muscle will develop more tension as a result of the summation of the contraction of the muscle fiber through progressive mechanical shortening. RUSSIAN STIMULATION SUMMARY Increases in intensity spreads the current over a larger area and increases the number of motor units activated by the current. Increases in the duration of the current also will cause more motor units to be activated. RUSSIAN STIMULATION SUMMARY Electrically stimulated muscle contractions are used clinically to: 1 . Help with muscle re-education 2 . Muscle contraction for muscle pumping action 3 . Reduction of swelling 4 . Prevention or retardation of atrophy RUSSIAN STIMULATION SUMMARY 5 . Muscle strengthening 6 . Increasing range of motion in tight joints. RUSSIAN STIMULATION SUMMARY It does appear that the intensity of contraction is positively correlated to strength gains. The stronger the contraction, the greater the gain. RUSSIAN STIMULATION 10/10 PRE-SET Physiological effects are as follows: 1.Decrease edema via pumping effect 2.Break spasms by fatigue of muscles 3.Increase blood flow 10/10 PRE-SET INDICATIONS Muscle spasms Edematous situations 10/10 PRE-SET PAD PLACEMENT Bipolar technique Origins and insertions and/or you see a muscle contraction that is tolerable to the patient. Polarity not important RUSSIAN STIMULATION RUSSIAN STIMULATION Questions regarding Russian stimulation therapy? BIPHASIC STIMULATION COURSE # 6106 DR. GRANT BIPHASIC THERAPY In Biphasic stimulation mode the ouput of the modality allows you to choose a muscle contraction/relaxation cycle that is most suited for the individual patient and for the desired treatment. When the cycle is chosen, each musclestimulating burst is followed by a relaxation (rest) cycle. BIPHASIC THERAPY There are 3 modes of treatment in Biphasic stimulation: 1 . Normal 2 . Reciprocal 3 . Co-Contraction You will need to decide which mode is to be used and attach the appropriate number of leads needed before setting up the treatment. BIPHASIC THERAPY Normal: Use one channel with one lead wire (two electrodes) The contraction/relaxation cycle is selected from an option list of 10/10, 10/30, 10/50 and continuous (there is no rest cycle with continuous). The continuous cycle is not recommended for EMS. BIPHASIC THERAPY Co-Contraction: Use two channels and two lead wires (four electrodes). Each pair of electrodes is placed over a different muscle group. This treatment fires the two muscle groups simultaneously - Contraction and rest cycles for both treatment areas occur at the same time. Two channels are required (1 and 2) BIPHASIC THERAPY Reciprocal: Use two channels and two lead wires (four electrodes) for this treatment. The reciprocal muscle stimulation fires two muscle groups (such as flexors/extensors) one after the other. Example: 10/30 setting, the modality would deliver stimulation for 10 seconds to the first muscle followed by 10 seconds of stimulation to the reciprocal muscle. BIPHASIC THERAPY Press the Biphasic key Choose the treatment mode Choose the contraction/rest times Choose the ramp setting Raise the intensity to the desired level For co-contraction or reciprocal treatments, choose the second channel and set the intensity for this channel Press start BIPHASIC THERAPY When choosing the Biphasic function, the default settings are automatically selected: 1 . Normal treatment mode 2 . 10/30 contraction/rest times 3 . Ramp up and down time : .5 sec. Increase the intensity to the patients tolerance Press start BIPHASIC THERAPY CAUTION NEVER TURN THE POWER ON OR OFF WHILE THE UNIT IS CONNECTED TO THE PATIENT BIPHASIC STIMULATION Questions regarding Biphasic Therapy? HIGH VOLT THERAPY Course #6106 DR. GRANT 79 Pain Alliance Institute HIGH VOLTAGE THERAPY HV is a unidirectional, pulsed current of up to 500 V force and average current of 1.0 - 1.5 mA. Pulsed duration is generally between 20 and 200 microsec. 80 HIGH VOLTAGE THERAPY In the past, it has been customary to refer to these stimulators as “high voltage galvanic stimulators” This inaccurate use of the term “galvanic” has led many to claim a significant polarizing effect for HVG machines. HIGH VOLTAGE THERAPY Although these stimulators use DC, there is only a minimal polarizing effect and they are not capable of iontophoresis. HIGH VOLTAGE THERAPY The term galvanic refers to a continuous, nonpulsed current that is used for iontophoresis HIGH VOLTAGE THERAPY The traditional term “high voltage galvanism” is somewhat misleading, as clinicians tend to confuse and /or equate the effects of HVT with low-voltage galvanism. 84 HIGH VOLTAGE THERAPY Manufactures of HVT equipment offer guidelines for the choice of polarity in particular situations, but research has not yet substantiated these guidelines. Polarity appears relatively unimportant in many circumstances. 85 HIGH VOLTAGE THERAPY In contrast to low voltage, high voltage offers a more comfortable current that is safer to use and more universal in its application. Because of its high peak current and short pulse duration, penetration is deeper, with less sensory disturbance and less heat production. 86 HIGH VOLTAGE THERAPY EFFECTS Analgesia Edema absorption Muscle contraction Increased peripheral circulation 87 HIGH VOLTAGE THERAPY INDICATIONS Soft tissue injuries Sciatica Arthritic conditions Nonsystemic edema Muscle spasm, muscle reeducation Trigger Point therapy 88 HIGH VOLTAGE THERAPY CONTRAINDICATIONS Malignancy Patients with pacemakers Pregnancy Over open wounds Transcerebrally Cardiac conditions 89 HIGH VOLTAGE THERAPY If treating trigger points, acupuncture points, or motor points, use a probe instead of active pads. Turn the intensity to the level of mild sensory stimulation and probe the area to locate the exact location to be stimulated. 90 HIGH VOLTAGE THERAPY Continue to increase the intensity until the desired effect is achieved. Trigger points will usually become less painful in 15 - 30 seconds. 91 HIGH VOLTAGE THERAPY APPLICATION The treatment setup utilizes a double-output lead with two electrodes; an active and a dispersive electrode (monopolar technique). The size of the dispersive electrode is recommended to be double the area of the active electrode. HIGH VOLTAGE THERAPY APPLICATION If desired, the active output of the lead may be bifurcated to attach additional active electrodes; however, the combined total of the active electrodes must be less than the area of the single dispersive electrode. HIGH VOLTAGE THERAPY APPLICATION In the output labeled “HV” connect one lead with two output connections. It is best to use a lead that is marked to show the polarity of the output end. The active electrode is connected to the lead output that is marked positive The dispersive electrode is connected to the lead output that is marked negative. HIGH VOLTAGE THERAPY APPLICATION During treatment current flows in one direction between the electrodes. Polarity of the treatment is not controlled by the polarity of the lead wires, but is controlled by the polarity selection you make on the front panel of the unit. HIGH VOLTAGE THERAPY APPLICATION Changing the polarity in the treatment parameters has the effect of reversing the direction of the current flow between electrodes. It is important to attach the active electrode to the positive output of the lead wire to ensure the polarity you have selected is delivered. HIGH VOLT APPLICATION . . Press HV and choose polarity The available options include positive (+) , negative (-), or both. When both are selected, the unit alternates between the two, delivering each polarity for approximately 30 seconds. Choose the contraction/rest cycle times. . HIGH . . . . VOLT APPLICATION Choose the Ramp setting Choose High or Low pulse rate range. High is for acute and Low is for chronic Raise the intensity to the patients tolerance. Press Start . HIGH VOLT APPLICATION Default settings are as follows: . 10/30 contraction/rest times 2 . Treatment time - 10 minutes 3 . Ramp up and down time - .5 sec. 4 . Pulse rate: High Range - 80-120 Hz, Low Range - 1-10 Hz, available range - 1-200 Hz 5 . Raise intensity level to patients tolerance 6 . Press start HIGH VOLT THERAPY HIGH VOLT THERAPY Questions regarding High Volt therapy? LOW VOLTAGE STIMULATORS Dr. Grant LOW VOLTAGE THERAPY Low frequency alternating currents are utilized because of the continued need for electrical stimulation of atrophied muscle, especially for patients with CNS lesions. 107 LOW VOLTAGE THERAPY When low volt AC current of sufficient intensity is applied to the muscle, a contraction will be noted as long as the current is allowed to flow. The muscle will contract in time with the frequency(or pulses per second). At one pulse per second, the muscle will contract and relax once per second. LOW VOLTAGE THERAPY As the frequency is increased, the muscle pumps faster until you reach a stage (approximately 35 pps) where the muscle is incapable of relaxing before the next electrical pulse arrives ( a “tetanized” contraction). A steady contraction is noted . As you progress beyond 35 pps, the contraction becomes stronger. LOW VOLTAGE THERAPY EFFECTS Contraction of enervated muscle Pain relief Edema reduction 110 LOW VOLTAGE THERAPY INDICATIONS Stimulation of weak and/or atrophied muscles Nonsystemic edema pain syndromes 111 LOW VOLTAGE THERAPY CONTRAINDICATIONS Through the brain, heart or eyes Over bony prominences Fractures Skin lesions Malignancy Anesthetic areas Over a gravid uterus 112 LOW VOLTAGE THERAPY Application Place pads firmly on treating parts; can use hot packs, for combination therapy. Quadrapolar or bipolar technique may be used. If unequal sized pads, (monopolar technique) is used, the smaller pad will produce a greater effect. 113 LOW VOLTAGE THERAPY APPLICATION A probe may be used for specific stimulation of motor points. Set mode to: Pulse, if a gentle treatment is desired, to avoid further trauma or to disperse fluid. Set mode to: Surge, if a series of muscle contractions is desired (e.g.., for muscle re-education) 114 LOW VOLTAGE THERAPY APPLICATION Set mode to: Tetanize, if a tetanic contraction is desired to fatigue the muscle (e.g.., for muscle spasm or muscle tension) Choose the pulse width, “on ramp” time, and/or “off ramp” time. Set the timer to desired time 115 LOW VOLTAGE THERAPY APPLICATION Increase the intensity slowly to patient tolerance or until the desired muscle contraction is achieved. Treatment duration depends on the effect desired and the integrity of the muscle being stimulated 116 LOW VOLTAGE THERAPY APPLICATION Dr. Kots of the Soviet Union has suggested the following times: To increase circulation: 2 sec on, 2 sec off To reduce spasm and pain: 12 sec on, 8 sec off For strength endurance, and velocity: 10 sec. on, 50 sec. off 117 Questions regarding Low Voltage therapy? IONTOPHORESIS Dr. Grant IONTOPHORESIS Iontophoresis is a therapeutic technique that involves the introduction of ions into the body tissues by means of a direct electrical current. The manner in which ions move in solution forms the basis for iontophoresis. IONTOPHORESIS Positively charged ions are driven into the tissues from the positive pole, and negatively charged ions are introduced by the negative pole. The force that acts to move ions through the tissues is determined by both the strength of the electrical field and the electrical impedance of tissues to current flow. IONTOPHORESIS The quantity of ions transferred into the tissues through iontophoresis is determined by the intensity of the current or current density at the active electrode, the duration of the current flow, and the concentration of ions in solution. IONTOPHORESIS Continuous direct current must be used for iontophoresis, thus ensuring the unidirectional flow of ions that cannot be accomplished using a bi-directional or alternating current. Electrodes may be either borrowed from other ES or commercially manufactured ready-to-use disposable electrodes. IONTOPHORESIS Iontophoresis is used to treat Inflammatory musculoskeletal conditions, for analgesic effects, scar modification, wound healing, and in treating edema, and calcium deposits. Probably the single most common problem associated with iontophoresis is a chemical burn that usually occurs as a result of the DC itself and not because of the ion being used in treatment IONTOPHORESIS Neither high-voltage direct current or interferential currents may be used for iontophoresis since the current is interrupted and the current duration is too short to produce significant ion movement. Recommended current amplitudes used for iontophoresis range between 3 and 5 mamp. IONTOPHORESIS Recommended treatment durations range between 10 and 20 minutes, with 15 minutes being average. During this 15 minute treatment, the patient should be comfortable with no reported visible signs of pain or burning. The doctor should check the patient’s skin every 3-5 minutes during treatment, looking for signs of skin irritation. IONTOPHORESIS Since skin impedance usually decreases during the treatment, it may be necessary to decrease current intensity to avoid pain or burning. IONTOPHORESIS ELECTRODES The commercially produced electrodes are sold with most iontophoresis systems. These electrodes have a small chamber, into which the ionized solution may be injected, that is, covered by some type of semipermeable membrane. The electrode self-adheres to the skin. IONTOPHORESIS ELECTRODES This type of electrodes has eliminated the “mess and hassles” that have been associated with electrode preparation for iontophoresis in the past. Once the electrode has been prepared. It then becomes the active electrode, and the lead wire to the generator is attached such that the polarity of the wire is the same as the polarity of the ion in solution. IONTOPHORESIS ELECTRODES A second electrode, the dispersive electrode, is prepared with water, gel, or some other conductive material as recommended by the manufacture. Both electrodes must be securely attached to the skin such that uniform skin contact and pressure is maintained under both electrodes to minimize the risk of burns. IONTOPHORESIS ELECTRODES The size and shape of the electrodes can cause a variation in current density and affects the size of the area treated. Smaller electrodes have a higher current density and should be used to treat a specific lesion. Larger electrodes should be used when the target treatment area is not welldefined. IONTOPHORESIS ELECTRODES Recommendations for spacing between the active and dispersive electrodes seem to be variable. They should be separated by at least the diameter of the active electrode. One source has recommended spacing them at least 18 inches apart. IONTOPHORESIS ELECTRODES As spacing between the electrodes increases, the current density in the superficial tissues will decrease, perhaps minimizing the potential for burns. CLINICAL APPLICATIONS FOR IONTOPHORESIS Clinically, iontophoresis is most often used in the treatment of inflammatory musculoskeletal conditions. It may be used for analgesia, scar modification, wound healing, and in treating edema, calcium deposits, and hyperhidrosis. IONTOPHORESIS Conditions Treated Spasm: Calcium, magnesium Inflammation: Hydrocortisone, salicylate dexamethosone. Analgesia: Lidocaine, magnesium Edema: Magnesium, mecholyl, hyaluronidase, salicylate Ischemia: Magnesium, mecholyl, iodine Fungi: Copper INDICATIONS CONTRAINDICATIONS IONTOPHORESIS Questions regarding Iontophoresis? TENS DR. GRANT 140 Pain Alliance Institute TENS TENS should apply to any form of electrical stimulation that is applied via surface electrodes. The term has been used for small portable stimulators that can be attached to the belt or clothing and used for various time periods for the relief of pain. 141 TENS In general the primary effect of TENS is the relief of pain. Many health practitioners are finding TENS to be an effective, safe, noninvasive, and cost effective method of treating acute, chronic and psychogenic pain of innumerable origins. 142 TENS There are two major theories of pain control, the mechanisms of which are considered to be operative when using TENS: gate control and opiate-mediated control. TENS According to the opiate-mediated theory of pain control, endorphins are released in the body and bind to specific receptor sites in the CNS and PNS to decrease pain perception and nociceptive responses. TENS ES has been shown to increase the levels of endorphins circulating in the cerebrospinal fluid (CSF) of patients with various neurological disorders, and pain perception in these patients is reduced with ES. ES controls pain by inducing the release of endogenous opiates. TENS Other proposed mechanisms of pain control include enhancement of tissue healing, modification of the flow of energy in acupuncture meridians, and placebo effects. TENS INDICATIONS Chronic pain Acute pain Intractable pain (TENS can provide adequate relief of pain secondary to malignancy). Results are best with trunk and extremity pain and worst with pelvic and perineal pain. 147 TENS INDICATIONS Rehabilitation: The use of TENS for the reduction of pain during rehabilitation can increase performance and shorten disability. Care must be taken to not allow the TENS to obliterate pain to the extent that the patient loses protective cues and overstresses the part being rehabilitated. 148 TENS CONTRAINDICATIONS Pacemakers Carotid nerve stimulation Laryngeal stimulation During pregnancy 149 TENS TREATMENT METHODS There are several different methods for delivering TENS for pain control. It may be necessary to try more than one method, or a combination of methods, with a given patient in order to find the most effective intervention for that individual. TENS TREATMENT METHODS The methods include the following: 1 . Sub-sensory level stimulation (MENS) 2 . Sensory level stimulation (High TENS) 3 . Motor Level stimulation (Low TENS) 4 . Noxious level stimulation Sub-sensory level stimulation Also referred to as subliminal stimulation or microcurrent electrical nerve stimulation. Delivers current at intensities that are below threshold for nerve depolarization. The literature does not contain clear or consistent methods of manipulating parameters for pain control using this type of stimulation. SENSORY LEVEL STIMULATION Is commonly referred to as conventional or highTENS This method of pain control is considered to operate via the gate control mechanism. It is most commonly used for controlling pain during the acute stages of injury, but it may also be effective in chronic situations. SENSORY LEVEL STIMULATION The onset of the decrease in the nociceptive response is relatively quick, generally within 5 minutes of initiating the stimulation; however, the decrease does not generally last beyond 1 hour after the stimulation is stopped. MOTOR LEVEL STIMULATION Also known as Low TENS or acupuncture like TENS is thought to operate via an opiate-mediated mechanism involving the release of endorphins, although there may be a gating effect with motor-level TENS because sensory level fibers are also activated during treatment. MOTOR LEVEL STIMULATION Motor level TENS is commonly used in chronic presentations of pain. If sensory level TENS is ineffective in chronic cases and the patient can tolerate muscle contractions. The onset of of pain relief with this type of treatment is not usually immediate, requiring approximately 15-60 minutes of stimulation. MOTOR LEVEL STIMULATION The pain relief may last for hours or more after stimulation ceases, which is no longer expected with sensory level TENS. NOXIOUS LEVEL STIMULATION Opiate mediated Most commonly used for treatment of patients with chronic pain when the two previously methods of TENS have been unsuccessful. Onset of pain relief is usually rapid within seconds or minutes of ES stimulation. NOXIOUS LEVEL STIMULATION The duration of pain relief is thought to be similar to that achieved with motor level TENS. When applying noxious level stimulation, the intent is to produce by either sensory and or motor stimulation. NOXIOUS LEVEL STIMULATION A painful response can be produced without a muscle contraction if electrodes are placed over an area that does not have superficially located motor nerve fibers. TENS ELECTRODE PLACEMENT Electrode placement is one of the most critical factors for the success of TENS Directly over or around the painful site Over trigger points 161 TENS ELECTRODE PLACEMENT Over acupuncture points Within a specific dermatome At the site of the corresponding nerve root. TENS The most significant complication of TENS is local skin rashes produced by the conduction gel or tape. Electrodes should be removed every day or two to clean the skin and inspect the area. 163 ELECTRODES Initially, dry pads were provided that required the use of gel. This was messy, provided uneven conductivity, and caused minor skin burns at high currents. At present, self-adhesive electrodes are available that are semi-disposable and generally affordable. ELECTRODES Most TENS devices recommend carbon based electrodes. In this day and age of concern over deadly infectious diseases, it has become common practice for practitioners who use TENS clinically to keep a separate set of electrodes for the exclusive use of each patient. TENS There is no contraindications to 24 hour use of “high TENS”. “Low” TENS”, however, should be used only 30 - 40 minutes at a time, as “Low TENS” causes muscle contraction and may cause soreness if used for longer periods. 166 HiTENS The term TENS is often associated with the application of a high frequency, low-intensity current that is directed at closing the pain gate. This is sometimes referred to as conventional TENS, classic TENS, or High TENS. HIGH TENS This particular form of TENS typically uses a spike or asymmetric rectangular wave with a pulse width of less than 200 microseconds. The frequency range varies between 50 to 150 Hz and the intensity is set at a mild sensory level (gentle tingling). HIGH TENS The stimulation is towards the large superficial sensory fibers (A-beta) This type of stimulation usually provides a fairly rapid and comfortable form of pain relief. HIGH TENS With this type of application, the onset of pain suppression usually occurs within minutes and lasts for approximately I hour after stimulation. HIGH TENS Stimulation times vary considerably from patient to patient. They may be as short as 15 minutes in some with no return of pain. others, such as immediate postsurgical patients, may find it helpful to leave the TENS on for hours at a time. HIGH TENS The electrode type, quality, and contact affect the level of comfort and the effectiveness of the procedure. Electrode placement is important to effect a positive response. HIGH TENS This high frequency form of TENS appears to work best when electrodes surround the injured area or are applied within the same spinal segments as the pain HIGH TENS The electrode position and intensity should be adjusted so that tingling can be felt throughout the area of pain. Electrode placement may need to be altered several times to supply adequate pain relief. LOW TENS This form of TENS is intended to produce analgesia by stimulating the release of endorphins and enkaphalins. It is also referred to as “acupuncture-like TENS” or “noninvasive electroacupuncture.” It uses a high-intensity current and a very low frequency (1-5 Hz) LoTENS It appears that the higher the intensity of the stimulation, the greater the physiologic response. Unlike other forms of ES, Low TENS applications appear to be frequency- dependent with little room for variation. LOW TENS The mechanism of action is via the release of endorphins and enkaphalins and because of the half-life of endorphins, the relief gained is typically longer lasting than that found with conventional TENS. LOW TENS The time required to induce any significant endorphin release is between 20 and 45 minutes. Low TENS application may provide relief in some patients who are resistant to conventional TENS. BURST TENS Burst TENS consist of clusters of high-frequency pulses or trains (70100 Hz) that are repeated at an acupuncture frequency of 1 to 5 Hz. The pulse width and amperage are variable The intensity is raised to a motor level stimulus BURST TENS The strength of the contraction varies from barely perceptible to strong rhythmic pulses. As with Low TENS, the evidence indicates that a stronger stimulation produces better analgesia. BURST TENS The mechanism of pain relief is thought to be mixed with some stimulation of superficial sensory fibers and some endorphin response. The major advantage of this modification over Low TENS is the level of comfort afforded. EFFECTIVENESS OF TENS The application of tens, particularly in the chronic pain patient can be enhanced or hindered by a variety of factors. the following factors may interfere with the successful application of TENS. FACTORS INTERFERING WITH SUCCESS OF TENS Medication - particularly corticosteroids, narcotics, and diazepam, can deplete the body of the chemicals necessary to control pain. FACTORS INTERFERING WITH SUCCESS OF TENS Prolonged Pain and Stress Patients who have been in pain for extended periods of time may fail to respond to TENS for many reasons including depression. FACTORS INTERFERING WITH SUCCESS OF TENS Senility - interferes with patient understanding and the manual dexterity necessary both to connect electrodes and to control the TENS devices. FACTORS INTERFERING WITH SUCCESS OF TENS Patient Understanding - As with other forms of treatment, compliance lessens if patients do not understand the purpose of the therapy, patients who are treated with TENS, especially those who use TENS units on an outpatient basis, should be informed- FACTORS INTERFERING WITH SUCCESS OF TENS - regarding the purpose of treatment, the application techniques, electrode placement, and equipment use. Lack of co-operation - Patients who are unwilling to learn how to use the TENS unit properly or who are noncompliant probably will not respond well. FACTORS INTERFERING WITH SUCCESS OF TENS Poor Posture or Body Mechanics Many patients have pain due to sustained postural stresses and/or biomechanical dysfunction. FACTORS INTERFERING WITH SUCCESS OF TENS It is helpful to provide pain relief for these patients, it is also important to address such problems with appropriate ergonomic modifications and/or mechanical therapies to eliminate or minimize any continued aggravation. FACTORS THAT ENHANCE THE APPLICATION OF TENS Wean from Medications Appropriate communication with medical providers is necessary to determine the most effective painrelieving approach. FACTORS THAT ENHANCE THE APPLICATION OF TENS Tryptophan A naturally occurring sedative, a precursor of serotonin, aids in reducing pain and stress levels. It is found in high quantities in eggs, meat, poultry, and dairy products. FACTORS THAT ENHANCE THE APPLICATION OF TENS Stress Reduction - Reducing and eliminating stress helps improve the efficacy of TENS. One of the most useful stress reduction techniques is relaxation therapy FACTORS THAT ENHANCE THE APPLICATION OF TENS With practice, some patients may find that they can control their pain without the use of TENS or pharmaceuticals. FACTORS THAT ENHANCE THE APPLICATION OF TENS Current modulations - Patients rapidly accommodate or adapt to a steady stimulus. When TENS is used for a prolonged time it may be helpful to modify the application technique by using different forms of TENS or by varying the current parameters. FACTORS THAT ENHANCE THE APPLICATION OF TENS Variable Electrode Placements - As with varying the parameters of stimulation, it is often helpful to vary the electrode placement , which not only helps to reduce patient accommodation, it also reduces the likelihood of skin irritation. FACTORS THAT ENHANCE THE APPLICATION OF TENS Patient Willingness to Cooperate and Experiment - Patient motivation is always a major factor in determining response to treatment, whether it includes TENS, manipulation, or exercise. FACTORS THAT ENHANCE THE APPLICATION OF TENS Improvement in Posture and Body Mechanics - Improving the working and living conditions of the patient may prevent or reduce many of the problems that produce and/or aggravate painful conditions TENS LONG TERM EFFECT As with many other treatment modalities, the long-term effectiveness of TENS is to a large extent determined by the manner in which it is originally presented to the patient. TENS LONG TERM EFFECT The success rate after several months of use varies widely, with some patients receiving significant relief whereas others may hardly be affected TENS LONG TERM EFFECT The success of TENS on a long term basis is dependent upon the willingness of both the doctor and the patient to experiment with different electrode placements, frequencies, intensities, and forms. Questions regarding TENS application? PAIN MANAGEMENT DR. GRANT PAIN MANAGEMENT APPROACHES Pharmacological approaches: 1 Systemic analgesics 2 Spinal analgesia 3 Local injections to painful structures Physical agents Multidisciplinary pain treatment programs TREATMENT GOALS The goals of treatment include: 1 . Eliminating the cause of pain 2 . Controlling the nociceptor input 3 . Reducing the degree of patient impairment BASIS OF GOALS These approaches are based on our current understanding of pain transmission and control mechanisms and may act by: 1 . Controlling inflammation 2 . Increasing binding to opiate receptors 3 . Modulating pain at the spinal cord level In addition, some treatment approaches also address the psychological and social aspects of pain. PAIN MGMT. APPROACHES Different approaches are appropriate for different situations and clinical presentations and are frequently most effective when used together. ALLEVIATION OF PAIN The primary intervention used to alleviate pain is the administration of pharmacological agents. Although pharmacological agents are often effective for this purpose, they can also produce a variety of adverse effects. ALLEVIATION OF PAIN The use of physical agents , which also effectively control pain in many cases while producing fewer adverse effects, may be more appropriate. Some patients, particularly those with chronic pain, may need integrated multidisciplinary treatment, which includes psychological as well as physiological therapies, in order to achieve pain relief . PHARMACOLOGICAL APPROACHES Pharmacological analgesic agents control pain by modifying inflammatory mediators at the periphery, altering pain transmission from the periphery to the cortex, or altering the central perception of pain. PHARMACOLOGICAL APPROACHES The selection of a particular pharmacological analgesic agent depends on: 1 . Cause of pain 2 . Length of time the individual is expected to need the agent. 3 . The side effects of the agent SYSTEMIC ANALGESICS Administration of a systemic analgesic is usually the primary method of pain management. It is easy to administer and inexpensive, and can be an effective and appropriate pain-relieving intervention for many patients. SYSTEMIC ANALGESICS A wide range of analgesic medications can be systemically administered orally or by other routes. These medications include nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, opiates and opiods, and antidepressants. NONSTEROIDAL ANTIINFLAMMATORY DRUGS NSAIDs have both analgesic and antiinflammatory properties and can therefore relieve pain from both inflammatory and non-inflammatory sources. The primary long-term complication of NSAID use is gastrointestinal irritation and bleeding. NONSTEROIDAL ANTIINFLAMMATORY DRUGS NSAIDs also cause decreased platelet aggregation and thus prolonged bleeding time. They can cause kidney damage, bone marrow suppression, rashes and anorexia., and decrease renal blood flow in dehydrated patients. SOURCES OF The first NSAID was aspirin. Ibuprofen (Motrin), naproxen sodium (Naprosyn, Aleve), and Piroxicam (Feldene), are now available over the counter and by prescription. NSAIDs are primarily administered orally, although one, ketoraolac (Toradol), is available for administration by injection. ACETAMINOPHEN Acetaminophen (Tylenol) is an effective analgesic for mild to moderately severe pain; however, unlike NSAIDs, it has no clinically significant anti-inflammatory activity. It is useful for those who cannot tolerate NSAIDs due to gastric irritation or when the prolongation of bleeding time caused by NSAIDs would be a disadvantage. ACETAMINOPHEN Prolonged use or large doses of acetaminophen can cause liver damage; this risk is elevated in the chronic alcoholic. Skin rashes are also an occasional side effect of this medication. OPIATES Opiates are narcotic drugs that contain opium, derivatives of opium, or any of several semisynthetic or synthetic drugs with opium-like activity. Morphine, hydro-morphone, fentanyl, and meperidine are examples of opiates commonly used for clinical applications. OPIATES It has been proposed that opiates provide analgesia by mimicking the effects of endorphins and binding to opiate-specific receptor sites in the CNS. Opiates, when given in sufficient doses, will control even the most severe acute pain with tolerable side-effects . OPIATES They control pain that cannot be relieved by non-narcotic agents and are most effective when the pain is dull and poorly localized. OPIATES The side effects of opiates, including nausea, vomiting, sedation, suppression of cough, gastrointestinal mobility, and respiration, as well as their propensity to cause physical dependence and depression with long-term use, limit their application for the long term management of musculoskeletal pain. OPIATES Respiratory depression also limits the dose that can be used even for short term administration. Opiates are generally used clinically to relieve postoperative pain or pain due to malignancy. OPIATES Opiates can be delivered my mouth, intravenously, or by direct intra-articular injection. A popular and effective means of administration , particularly for hospitalized patients, is patientcontrolled analgesia (PCA). OPIATES With PCA, patients self-administer small, repeated intravenous doses via a pump. The amount of medication delivered is limited by pre-establishing dosing intervals and maximum doses within a defined period. OPIATES Pain control is more effective and adverse effects are less common with this means of administration than with more conventional physician-controlled opiate administration methods. ANTIDEPRESSANTS Antidepressants, particularly the tricyclics such as amitryptiline (Elavil), have been found to be an effective adjunctive component of chronic pain treatment, with smaller doses being effective for this application than those typically used for the treatment of depression. ANTIDEPRESSANTS The efficacy of these drugs for the treatment of chronic pain is thought to be related to their effects on sleep, nerve function, and mood. It has been found that patents with chronic pain who are also depressed report much higher levels of pain and show more pain related behaviors than those who are not depressed. ANTIDEPRESSANTS Although it is not certain if the higher level of pain in such patients is the cause or the product of their depression, the use of antidepressants in either situation may prove beneficial. SPINAL ANALGESIA Pain relief may be achieved by the administration of drugs such as opiates, local anesthetics, or corticosteroids into the epidural or subarachnoid space of the spinal cord. SPINAL ANALGESIA The route of administration provides analgesia to the areas innervated by the segments of the cord receiving the drug and is therefore most effective when the pain has a spinal distribution, such as a dermatomal distribution in a single limb. SPINAL ANALGESIA The primary advantages of this route of administration are that the drug bypasses the blood-brain barrier and that high concentrations reach the spinal cord at sites of nociceptive transmission and at opiate receptors, thus increasing the analgesic effects while reducing adverse effects. SPINAL ANALGESIA Opiates administered spinally exert their effects by stimulating opiate receptors in the dorsal horn of the spinal cord. When administered spinally, fat soluble opiates have a rapid onset and a short duration of action, whereas water soluble opiates have a slow onset and a more prolonged duration of action. SPINAL ANALGESIA Local anesthetics delivered spinally have the unique ability to completely block nociceptive transmission; however, with increasing concentration, these drugs also block sensory and then motor transmission, causing numbness and weakness. SPINAL ANALGESIA High doses of these drugs can also cause hypotension. These side effects of local anesthetics limit their application to the short-term control of pain and diagnostic purposes. SPINAL ANALGESIA Catabolic corticosteroids, such as cortisone and dexamethasone, can be administered to the epidural or subarachnoid space in order to relieve pain due to inflammation of the spinal nerve roots and/or surrounding structures. SPINAL ANALGESIA These drugs inhibit the inflammatory response to tissue injury; however , due to the side effects of repeated or prolonged use, including fat and muscle wasting, osteoporosis, and symptoms of Cushing’s syndrome, these drugs are not suitable for long-term application. LOCAL INJECTION Local injection of a corticosteroid and/or a local anesthetic can be particularly effective for relieving pain associated with local inflammation. Such injections can be administered into joints, bursae, trigger points, or around tendons and can be used for therapeutic purposes, to relieve pain, and/or for diagnostic purposes, to help identify the structures at fault. LOCAL INJECTION Although this type of treatment can be very effective, repeated local injections of corticosteroids are not recommended because they can cause tissue breakdown and deterioration. Local injections of corticosteroids directly after acute trauma are also not recommended because these drugs reduce the inflammatory response and may thus impair healing. LOCAL INJECTION Local injections of anesthetics generally provide only short-term relief and are therefore used primarily during painful procedures or diagnostically. PHYSICAL AGENTS Many physical agents effectively control or relieve pain. They exert this effect by moderating the release of inflammatory mediators, modulating pain at the spinal cord level, altering nerve conduction, and.or increasing endorphin levels. PHYSICAL AGENTS They also may indirectly reduce pain by decreasing the sensitivity of the muscle spindle system,thereby reducing muscle spasms, or by modifying vascular tone and the rate of blood flow, thereby reducing edema or ischemia. In addition, physical agents may reduce pain by helping to resolve the underlying cause of the painful sensation. PHYSICAL AGENTS Different physical agents control pain in different ways, Cryotherapy - controls acute pain in part by reducing the metabolic rate and thus reducing the production and release of inflammatory mediators such as serotonin, histamine, bradykinin, substance P, and prostaglandins. PHYSICAL AGENTS These chemicals cause pain directly by stimulating nociceptors and indirectly by impairing the local microstimulation and, in so doing, can damage tissue and impair tissue repair. Reducing the release of inflammatory mediators can thus directly relieve pain caused by acute inflammation and may directly limit pain by controlling edema and ischemia. PHYSICAL AGENTS These short term benefits can also optimize the rate of tissue healing and recovery. Cryotherapy, thermotherapy, electrical stimulation, and traction, which provide thermal, mechanical, or other nonnociceptive sensory stimuli, are thought to alleviate pain in part by inhibiting pain transmission at the spinal cord. PHYSICAL AGENTS Physical agents that act by this mechanism can be used for the treatment of acute and chronic pain because they do not generally produce significant adverse effects or adverse interactions with drugs, and they do not produce physical dependence with prolonged use. PHYSICAL AGENTS They are also effective and appropriate for pain caused by conditions that cannot be directly modified, such as pain caused by malignancy or a recent fracture, and for pain due to peripheral nervous system pathology, such as phantom limb pain, and peripheral neuropathy. PHYSICAL AGENTS Electrical stimulation is also thought to control pain in part by stimulating the release of endorphins at the spinal cord and at higher levels. This belief is supported by the finding that pain relief by certain types of electrical stimulation is reversed by naloxone. PHYSICAL AGENTS Physical agents have a number of advantages over other pain-modifying interventions. They are associated with fewer, and generally less severe, side effects than pharmacological agents. The adverse effects from using physical agents to control pain are generally localized to the area of application and are easily avoided with care in applying treatment. PHYSICAL AGENTS Patients also do not develop dependence on physical agents, although they may wish to continue to use them even after they are no longer effective because they enjoy the sensation or attention associated with their application. PHYSICAL AGENTS Physical agents also do not generally cause a degree of sedation that would impair an individual’s ability to work or drive safely. Many physical agents have the additional advantage of being readily used by patients independently to treat themselves. PHYSICAL AGENTS This type of treatment can also assist in containing the costs of medical care. Physical agents, used either alone or in conjunction with other interventions, such as pharmacological agents, manipulation, exercises, can also help remediate the underlying cause of pain while controlling the pain itself. MULTIDISCIPLINARY PAIN TREATMENT PROGRAMS Over the past two to three decades, multidisciplinary programs have been developed specifically for the treatment of chronic pain. Goals of treatment also generally include decreasing dependence on health care personnel and pain relieving medications, particularly habit forming opiates or other narcotics, increasing physical activities, MULTIDISCIPLINARY PAIN TREATMENT PROGRAMS Referral to alternative health care providers, and returning patients to their usual social roles. A number of studies have shown that multidisciplinary pain treatment programs do result in increased functional activity levels while reducing pain behaviors and the use of medical interventions in patients with chronic pain MULTIDISCIPLINARY PAIN TREATMENT PROGRAMS These programs have also been shown to be cost effective. MICROCURRENT DR. GRANT 255 Pain Alliance Institute MICROCURRENT This type of electrical modality uses an electrical current of less than 1 mA. They are subthreshold in nature and patients usually do not experience either the tingling sensation or muscle contraction seen with other electrical stimulators. MICRO CURRENT THERAPY EFFECTS Changes in cell wall permeability Increased intracellular concentration of Ca. Increased ATP production Increased protein synthesis Increased fibroblast activity 257 MICRO CURRENT THERAPY The most widely accepted view concerns the effect these small currents have on the cell membrane. It is generally accepted that microamperage current produces two important effects: 1 .“opens” voltage sensitive ion channels in the cell membrane 258 MICRO CURRENT THERAPY 2 .Increases the intracellular concentration of Ca and Na ions Damaged tissue releases a variety of pain producing substances including arachidonic acid. Arachidonic acid, in turn, is used in the synthesis of prostaglandin's and is associated with the production of histamine and bradykinins. 259 MICRO CURRENT THERAPY 3 .Chemical agents (pharmaceuticals) that interfere with the process. The most permanent approach to relieving pain would be to stimulate the intracellular mechanisms that would repair the damaged membranes that are responsible for the leakage of the pain-blocking agents. 261 MICRO CURRENT THERAPY It is postulated that microamperage stimulation functions to repair the injured cell membrane which, in turn, leads to a reduction of pain. Perhaps the most troubling area in the use of microamperage stimulation devices is the lack of understanding and uniformity of stimulation parameters. 262 MICRO CURRENT THERAPY To date, selection of appropriate parameters (frequency, intensity, pulse width, duration of treatment, etc.) are largely based on empirical observations and clinical experience. It does appear that the following parameters represent reasonable suggestions based on the available data. 263 MICRO CURRENT THERAPY Direct current is preferred due to the fact that it has a polarizing effect. Polarity - this may be the most crucial factor. It is generally accepted that a positive current is most useful in the early phases of treatment and a negative current in later phases. 264 MICRO CURRENT THERAPY Pulse width - in order to make the stimulus sufficient to change the cell membrane potential, it appears that a relatively long pulse width is necessary. Pulse widths vary from 50 microseconds to as long as .5 seconds. 265 MICRO CURRENT THERAPY Frequency - Acupuncture point stimulation appears to be most effective at low pulse rates, between 1-5 Hz. Pulse rates with microcurrent stimulation devices range from .5 per second to several hundred per second. 266 MICRO CURRENT THERAPY It is suggested that lower pulse rates are used for chronic conditions and higher pulse rates for more acute problems. 267 MICRO CURRENT THERAPY POINT STIMULATION Although microcurrent probe technique requires the active participation of the doctor or therapist, many believe that pain relief and an increase in joint range of motion can be accomplished in far less time than needed for other electrotherapy modalities. 268 MICRO CURRENT THERAPY PROBES Typically, the initial stage of treatment uses a hand-held probe that is either a solid blunt probe or a probe with a moistened cotton swab inserted within the hollowed tip of the probe. 269 MICRO CURRENT THERAPY PROBES When using probes, first affix new felt electrodes and saturate them with saline solution. Then apply firm pressure, but less than that which would cause more pain. 271 MICRO CURRENT THERAPY PROBES Tap water does not work well in most places anymore because of recent advances in desalination during water processing. As saline is a prescription product in the U.S., you can use contact lens cleaner, a conveniently packaged and inexpensive overthe-counter form of saline. MICROCURRENT APPLICATION For extremely hypersensitive people, such as fibromyalgia patients, it is better to start with a minimal amount of current. Even low level Micro currents may be uncomfortable in some patients. Start with more sensitive electrodes in these patients ( carbon, silver electrodes, probes with tap water) MICROCURRENT APPLICATION The patient should be in a relaxed position to receive maximum beneficial effects. The most important variable is the position of the probes, or pads. Place the probes or electrodes in such a way that if a line was drawn between them, that line would transect the problem area. MICROCURRENT APPLICATION Keep in mind that the electrode positioning may be transient, working well one day, but ineffective another day. As the problem begins to resolve, the electrode locations may require constant adjustments MICRO CURRENT THERAPY Many doctors are familiar with acupoints, motor points, and trigger points and are experienced in their electrostimulation. Once these points are isolated, the current is set to a subsensory level and the points are stimulated (15 seconds). 276 MICRO CURRENT THERAPY NERVE ROOT TECHNIQUE In this method, both probes are used to stimulate adjacent interspinous spaces of involved vertebral segments for 12 - 20 seconds. Significantly enhanced pain control and improved segmental ROM have been reported when using this technique. 277 MICRO CURRENT THERAPY Enhancing restricted joint motion has been reported to be highly effective when combined with passive mobilization of the involved joint. Results are typically greater than when passive exercise is used alone to increase joint ROMs. 278 MICRO CURRENT THERAPY PAD TREATMENT When pads are used, placement is proximal and distal to the site of involvement. 279 MICRO CURRENT THERAPY INDICATIONS Pain Tissue healing, including decubitus ulcers Several microamperage stimulators are being used for the treatment of acute and chronic sports injuries because of their analgesic, antiinflammatory, and healing properties 280 MICRO CURRENT THERAPY CONTRAINDICATIONS Demand - type cardiac pacemakers Over the carotid sinus Over the eyeball or eyelid Safety and effectiveness of microamperage stimulators has not been established in pregnancy; avoid the stimulation of any area that might affect the pregnancy. 281 MICOCURRENT These units are not designed to stimulate a muscle contraction As a result, these units are now referred to as LIS (Low intensity stimulators). These currents still have a direction, and both AC and DC waveforms are available. MICROCURRENT Questions regarding Microcurrent therapy? COMBINATION THERAPY In a clinical setting it is not uncommon to combine modalities to accomplish a specific treatment goal. Ultra sound is frequently used with other modalities including cold packs, and electrical stimulating currents. Pulsed ultrasound could be used after ice application if the goal is pain reduction and healing in the acute stage. ULTRASOUND AND ESC The combination of these two are frequently used. Electrical stimulating currents are used for analgesia or producing muscle contraction. Ultrasound and ESC in combination have been recommended in the treatment of myofascial trigger points. ULTRASOUND AND ESC Both modalities provide analgesic effects, and both have been shown to be effective in reducing the pain-spasmpain cycle, although the mechanisms responsible are not clearly understood. ESC & ULTRASOUND CONNECTION IN BACK OF ULTRASOUND BACK OF UNIT CONNECTION BANANA PLUG QUESTIONS REGARDING COMBINATION THERAPY?